Another EMTALA Violation...

[thegenius]

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Can you believe this stuff still happens?

Civil Monetary Penalties and Affirmative Exclusions | Office of Inspector General | U.S. Department of Health and Human Services

Alabama Hospital Settles Case Involving Patient Dumping Allegations
On December 21, 2018, Mobile Infirmary Medical Center (MIMC), Mobile, Alabama, entered into an $80,000 settlement agreement with OIG. The settlement resolves allegations that, based on OIG's investigation, MIMC violated the Emergency Medical Treatment and Labor Act (EMTALA) when it failed to provide an adequate medical screening examination and stabilizing treatment for two individuals. The first patient, a 24-year-old male presented to MIMC's Emergency Department (ED) complaining of weakness and exhibited altered mental status. He was reportedly aggressive and non-compliant with staff directions. When he was leaving the ED he apparently collapsed. A security guard, a hospital employee, put him in a wheelchair and wheeled the patient off hospital property - where he was left on the ground. Approximately four hours later the patient was found cold, with decreased responsiveness. He was transported to another hospital by ambulance. He died two weeks later. The second patient, a 35-year-old male, presented to MIMC's ED accompanied by his girlfriend. The patient complained of shortness of breath and chest pain. The patient requested to see a physician and became belligerent when a nurse asked him why. That led to the patient being escorted out of the ED by security. Several minutes later, the patient returned to the ED. This time, the patient's girlfriend drove up to the ambulance bay and reported that the patient had suffered a seizure and was lying in her truck. She was informed by staff that they would not help get the patient out of the truck. In addition, the security guard told her she had to leave. The patient's girlfriend then took him to another hospital where he was pronounced dead within 20 minutes of his arrival. Senior Counsel Sandra Sands represented OIG.

 

[GeneralVeers]

Those are the allegations. Often the real story is somewhat different....

 

[thegenius]

Well...they settled. So there was probably some truth to the story.

 

[southerndoc]

We have signs posted in our ER that aggressive behavior toward staff will not be tolerated. I don't think our EMTALA obligation includes getting assaulted.

I think the aggressive patient being wheeled off property might have been appropriate. He was found cold? Probably was homeless in 30 degree weather. Well, yea, that's going to make someone hypothermic. If Walmart doesn't give someone a cookie because they have no money and later the person is found to have a glucose of 20, does that make Walmart at fault?

The second case said the patient became beligerant. Again, I would rather pay an EMTALA fine than take someone's abuse.

I've attended a group discussion led by Sandra Sands. She's hardcore. She told us that if a place calls and asks us to transfer a patient, we review the films and tell them that patient can go home (because we normally would discharge this kind of injury anyhow), that it is an EMTALA violation. Basically any request for transfer should automatically receive an answer of "yes!" unless we do not have capacity to take the patient.

 

[WilcoWorld]

I don't tolerate abuse, but having security wheel someone off of the premises is not a good way to handle a discharge.

Based on the available information those cases sound egregious.

 

[deleted109597]

I don't tolerate abuse, but having security wheel someone off of the premises is not a good way to handle a discharge.

Based on the available information those cases sound egregious.

Yep. Security is to help us, but if someone has to leave, that's up to the police. Call them. Don't use your own staff.

 

[Hercules]

I work in the same town as these cases and may or may not be at the hospital that these were taken to afterwards. I can see both sides of these arguments. The optics look terrible for these two cases, but as stated above there is frequently more to the story.

I also feel very strongly about violent patients and have a zero tolerance policy. You can be complaining of crushing chest pain, but if you assault me or my staff you’re out. We are here to help but no one has to put up with being punched, bitten, kicked, etc. One of these was said to be altered so that may be a slightly different scenario, but if you are completely aware of what you are doing and choose to assault a health care provider, then you belong in jail not in my ED.

 

[GeneralVeers]

Well...they settled. So there was probably some truth to the story.

That doesn't mean anything. Cases are settled frequently regardless of the actual facts. Often settling a case will make everyone's lives easier, especially the Plaintiff's Attorney who hits the jackpot.

 

[thegenius]

Have an EMTALA question.

Today my colleague was taking care of an elderly man with one kidney (other was removed for RCC) who presented with weakness, LH and some brown diarrhea for 3 days. He had normal vital signs and had a non-contributory physical exam. Workup showed worsening kidney disease, Cr now 4.5 (from 2.2 one year ago), K+ 6.3, and mild EKG changes. Specifically there are two T waves that have normalized, or pseudonormalized in the precordium. He did have a CT A/P non-contrast that showed no emergent findings or acute abdominal pathology, but did show a "Increasing size of infrarenal fusiform abdominal aorta now measuring up to 5.8 x 6.4 cm." The CT one year ago had those measurements at 5.2 x 5.7 cm. Lastly, while there is no IV contrast given, there is no evidence that it is leaking nor is there suspicion it is leaking based on exam. Moreover prior imaging many years ago with IV contrast showed no dissection flap, for what that's worth.

So my colleague began treating the elevated Cr and hyperK and spoke to the hospitalist, who asked that we speak to vascular first. Vascular said they could not handle that case at our institution (whether inpatient or outpatient) if something happened, like if it started leaking, needed emergent intervention, or even needed outpatient intervention. So the patient could go the entire time in the hospital having the Cr / HyperK addressed, but may not need emergent vascular intervention.

1. The patient has a medical emergency with the elevated Cr and HyperK with a single kidney, which is something our institution has the capacity to address.
2. The patient does NOT have a medical emergency with the stable(ish) and large AAA, but if something goes wrong during hospitalization our hospital does not have the capacity to address.

Assuming the patient is not asking to be transferred, is it an EMTALA violation to transfer the patient to another hospital for the elevated Cr, HyperK, and the stable(ish) AAA? While it would be certainly nice for the receiving hospital to accept the patient, are they obligated to do so?

I tend to think by the letter of the law it would be a violation, because the patient does not have a medical emergency with the AAA. It's like not admitting someone with pneumonia who has a large asymptomatic intracranial cerebral aneurysm (and no neurosurgery backup), or not admitting someone with leg cellulitis who has asymptomatic CAD with an 75-80% lesion (but no interventional cardiology backup).

 

[GonnaBeADoc2222]

Have an EMTALA question.

Today my colleague was taking care of an elderly man with one kidney (other was removed for RCC) who presented with weakness, LH and some brown diarrhea for 3 days. He had normal vital signs and had a non-contributory physical exam. Workup showed worsening kidney disease, Cr now 4.5 (from 2.2 one year ago), K+ 6.3, and mild EKG changes. Specifically there are two T waves that have normalized, or pseudonormalized in the precordium. He did have a CT A/P non-contrast that showed no emergent findings or acute abdominal pathology, but did show a "Increasing size of infrarenal fusiform abdominal aorta now measuring up to 5.8 x 6.4 cm." The CT one year ago had those measurements at 5.2 x 5.7 cm. Lastly, while there is no IV contrast given, there is no evidence that it is leaking nor is there suspicion it is leaking based on exam. Moreover prior imaging many years ago with IV contrast showed no dissection flap, for what that's worth.

So my colleague began treating the elevated Cr and hyperK and spoke to the hospitalist, who asked that we speak to vascular first. Vascular said they could not handle that case at our institution (whether inpatient or outpatient) if something happened, like if it started leaking, needed emergent intervention, or even needed outpatient intervention. So the patient could go the entire time in the hospital having the Cr / HyperK addressed, but may not need emergent vascular intervention.

1. The patient has a medical emergency with the elevated Cr and HyperK with a single kidney, which is something our institution has the capacity to address.
2. The patient does NOT have a medical emergency with the stable(ish) and large AAA, but if something goes wrong during hospitalization our hospital does not have the capacity to address.

Assuming the patient is not asking to be transferred, is it an EMTALA violation to transfer the patient to another hospital for the elevated Cr, HyperK, and the stable(ish) AAA? While it would be certainly nice for the receiving hospital to accept the patient, are they obligated to do so?

I tend to think by the letter of the law it would be a violation, because the patient does not have a medical emergency with the AAA. It's like not admitting someone with pneumonia who has a large asymptomatic intracranial cerebral aneurysm (and no neurosurgery backup), or not admitting someone with leg cellulitis who has asymptomatic CAD with an 75-80% lesion (but no interventional cardiology backup).

This is a BS transfer. Not sure if it actually violated EMTALA, but there is no chance this guy's insurance is going to cover that transport.

"I don't need a vascular consult in the ED. You can call one if you like."

Still don't want the admission?

"Let me call the CMO real quick."

 

[thegenius]

Yea I don't know. Apparently the vascular surgeon requested the pt be transfered. The problem with these cases is the pt stays in the ED for 24+ hours because you really can't transfer them but the hospitalist refuses to admit them, citing the vascular surgeon won't operate on the guy IF something bad happens.

 

[BoardingDoc]

Yea I don't know. Apparently the vascular surgeon requested the pt be transfered. The problem with these cases is the pt stays in the ED for 24+ hours because you really can't transfer them but the hospitalist refuses to admit them, citing the vascular surgeon won't operate on the guy IF something bad happens.

That is irrelevant. That is like saying you won't admit a patient for pneumonia who has a known brain aneurysm and no NSGY available. Yeah, it might rupture at literally any time. That is irrelevant. The argument that the patient needs to be admitted to a tertiary care center for all of their routine medical needs is absurd.

 

[southerndoc]

Not an EMTALA violation if you treated the hyperK in the ER. It's still a bad transfer. You should bring this up with your medical director so he/she can discuss at your next MEC meeting.

 

[Brigade4Radiant]

That is irrelevant. That is like saying you won't admit a patient for pneumonia who has a known brain aneurysm and no NSGY available. Yeah, it might rupture at literally any time. That is irrelevant. The argument that the patient needs to be admitted to a tertiary care center for all of their routine medical needs is absurd.

That happens at hospitals a lot they won’t take the liability

 

[John Red]

Have seen cases of specialist won’t manage which blows my mind. We have a “insert specialist” issue needing intervention, and specialist is requesting transfer because they are “uncomfortable”. These become nightmare screaming matches back and forth re: EMTALA and specialist refusing to manage. Call for transfer and inevitably (and rightfully so) facility balks stating that if you have X on call, and this is an X issue, there is no indication for transfer. Blows my mind how some of these specialists get paid to be on call, get upset when called, and refuse to manage patients.

 

[wolverine10k]

Have seen cases of specialist won’t manage which blows my mind. We have a “insert specialist” issue needing intervention, and specialist is requesting transfer because they are “uncomfortable”. These become nightmare screaming matches back and forth re: EMTALA and specialist refusing to manage. Call for transfer and inevitably (and rightfully so) facility balks stating that if you have X on call, and this is an X issue, there is no indication for transfer. Blows my mind how some of these specialists get paid to be on call, get upset when called, and refuse to manage patients.

Usually in that case I call the specialist back and tell them they need to come to the ED and arrange transfer of the patient. I’m done getting yelled at by the outside facility specialist, it’s on you now. “You’re the EMTALA doc on call, they have this problem that you specialized in and I need your help. So either take care of them here or help me arrange transfer by calling the other hospital.”

 

[Groove]

I've had better luck over the years playing the good cop routine on the specialist refusing care and recommending transfer. For starters, I always ask if he/she can specify to me why he/she feels they are unable to take care of X issue at our hospital. If they balk or get snappy I calmly just go "Look, I'm trying to help you out here and avoid an EMTALA violation so I need to be very clear when I'm on a recorded line with the other hospital and they are asking why we can't take care of this pt. What I understand you saying is that we are not equipped with adequate resources to take care of blah, blah, blah, is that correct?"

It's then a fairly straightforward transfer. It's either legit, or it isn't. If I feel I can adequately articulate the need for a transfer, then I'll make the call and generally can always make it happen. If I feel this is bogus, or I get significant pushback from the other hospital because they also know it's bogus... Then I would probably call the CMO/admin on call and tell them I'm about to initiate a transfer that has a high likelihood of being an EMTALA violation. That usually results in a quick phone call to the consultant and things get sorted out fairly quickly. Rarely, have I ever had to go that route but I think that's the most direct way to solve the problem instead of getting caught in screaming matches with your specialist or an outside specialist. One time I managed to even put the two surgeons on the phone and they hashed it out themselves. It's so incredibly counterproductive to get caught in the middle of these things but I totally get it.

In the above case by @thegenius I tend to agree with @GonnaBeADoc2222 in that I would push for admission and they can call vascular if they want to. If they insisted and vascular balked, then I'd probably need more specifics from the vascular surgeon i.e. "Are you asking for me to transfer the pt because you anticipate a surgical issue regarding his AAA during this hospitalization based on the information I've given you?" Pin him down and get him to articulate his reasoning better. It's either legit or not. Who knows, he might have a legit concern (based on the rapid expansion of the AAA, he feels it needs to be addressed on this hospitalization and/or fears he has high likelihood of complication and he does not have adequate resources at your hospital d/t x,y,z, etc.. and delayed surgical care would have a high likelihood of mortality, etc.. and that gives me better ability to articulate the transfer. If there are legitimate needs for additional resources then obviously that wouldn't constitute an EMTALA violation. If it's still bogus and he can't/won't help me out then as above, I would probably called CMO and inform them that to the best of my understanding, I'm being asked to transfer a pt with potential for an EMTALA violation and request their assistance with direction (so I can document everyone's name). In fact, on the transfer forms it asks you to list any physicians that have been consulted and refused care for the pt. The problem is that if you go this route, you're really going to stir up the hornets nest so cross your T's and dot your I's. Remember, in the grand scheme of hospital hierarchy, we are much more expendable than a vascular surgeon. Anytime I'm about to pull out the EMTALA card, I always want to make sure I really have a firm understanding of everyone's concerns. You could even go a step further and offer to have your surgeon talk to the outside vascular surgeon. Most of the times, you can virtually always talk your way out of these things. I think I've had to pull the EMTALA card like...twice, ever. One of those was when I was a brand new attending and definitely overreacted.

 

[thegenius]

Usually in that case I call the specialist back and tell them they need to come to the ED and arrange transfer of the patient. I’m done getting yelled at by the outside facility specialist, it’s on you now. “You’re the EMTALA doc on call, they have this problem that you specialized in and I need your help. So either take care of them here or help me arrange transfer by calling the other hospital.”

Yea and how often does that work? 100% of the time?

 

[TooMuchResearch]

Only once.

Yea and how often does that work? 100% of the time?

 

[wolverine10k]

Yea and how often does that work? 100% of the time?

My consultants are pretty easy to deal with so it’s a rare situation. The few times I tried it the consultants said “fine, just put them in and we’ll deal with it later.”

 

[RustedFox]

That is irrelevant. That is like saying you won't admit a patient for pneumonia who has a known brain aneurysm and no NSGY available. Yeah, it might rupture at literally any time. That is irrelevant. The argument that the patient needs to be admitted to a tertiary care center for all of their routine medical needs is absurd.

We had one hospitalist who would (no exaggeration) do this EVERY FREAKING TIME.
The patient has a known (aneurysm somewhere/chronic medical condition/etc)?
"Well, we dont' have that subspecialist, so they need to be transferred."
Often times, with the SAME patient. (Yep. YOU punted this one LAST time. No; I'm not letting you punt this one AGAIN. Knock it off.)
She is thankfully gone after the re-organization of the hospital.

We. All. Hated. Her.
So. Much.

 

[Hercules]

We had one hospitalist who would (no exaggeration) do this EVERY FREAKING TIME.
The patient has a known (aneurysm somewhere/chronic medical condition/etc)?
"Well, we dont' have that subspecialist, so they need to be transferred."
Often times, with the SAME patient. (Yep. YOU punted this one LAST time. No; I'm not letting you punt this one AGAIN. Knock it off.)
She is thankfully gone after the re-organization of the hospital.

We. All. Hated. Her.
So. Much.

My personal favorite at my hospital—At the time we had no NSGY coverage but did have ENT. Another hospital in my town had NSGY but no ENT. They called one night to transfer an intracranial bleed to me because he also had a nosebleed. I kid you not. I just said, “Yeah, I’m going to repeat back to you what you just said so you can hear how ridiculous it sounds.”

 

[deleted836128]

My personal favorite at my hospital—At the time we had no NSGY coverage but did have ENT. Another hospital in my town had NSGY but no ENT. They called one night to transfer an intracranial bleed to me because he also had a nosebleed. I kid you not. I just said, “Yeah, I’m going to repeat back to you what you just said so you can hear how ridiculous it sounds.”

OMG... that’s insane. I was going to admit a patient for some sort of surgical abdomen, I can’t remember what it was, and the patient had also mentioned a persistent nose bleed which I was able to cauterize with silver nitrate. No more bleeding. Not on anticoagulants. The hospitalist refused the admission because “His nose could bleed again and we don’t have ENT.”

 

[GeneralVeers]

I love when we have an ENT on-call and the house supervisor will come down to the busy ED and demand that I run upstairs to put packing in a bleeding nose of a patient who is on Eliquis. I always tell them two things:

1. I'm not required to do any procedures in hospital other than codes, and intubations
2. We have ENT on-call and being paid to do so and they should contact that person.

Some of our docs are actually dumb enough to go upstairs and do this kind of stuff.

 

[southerndoc]

ENT is likely not getting paid to be on call. Most health systems do not pay for call coverage except for those that are hard to get (hand surgery, facial trauma, etc.). ENT only gets paid for facial trauma call at my facility, but most facial trauma is covered by OMFS and plastics.

ENT is not required to respond to emergencies upstairs (just like the ER doc isn't). However, it's what's best for the patient. If ENT refuses to come in, I have no problem walking upstairs to pack a nose and bill for it. Then that ENT will be sitting in the VPMA's office the next business day defending himself.

 

[thegenius]

ENT is likely not getting paid to be on call. Most health systems do not pay for call coverage except for those that are hard to get (hand surgery, facial trauma, etc.). ENT only gets paid for facial trauma call at my facility, but most facial trauma is covered by OMFS and plastics.

ENT is not required to respond to emergencies upstairs (just like the ER doc isn't). However, it's what's best for the patient. If ENT refuses to come in, I have no problem walking upstairs to pack a nose and bill for it. Then that ENT will be sitting in the VPMA's office the next business day defending himself.

I've noticed at my place that there are "tiers" of consultants. Some of them are paid to be on call, some are not. ENT has told me before that they are not paid to be on call and they do it as a courtesy to the hospital. So basically they come in for real ENT emergencies like stridor, post-tonsillectomy bleeding, etc.

Interesting that what's best for the patient is to have someone other than the prima facie expert to go out of their way for a medical emergency.

 

[thegenius]

It's interesting that so much of the observed behavior in a health care system is driven around fear of litigation. Lawyers own our society.

If health care systems were protected against legal action we would have a more efficient and cheaper one.

 

[southerndoc]

Not saying ER physician is better than an ENT. Just making two points: (1) delay in care from ENT taking a while to get there and (2) ENT not coming in because they aren't obligated to do so.

EMTALA doesn't apply to admitted patients if their condition develops while they are admitted. If they present with an epistaxis that is uncontrollable and get admitted to the hospitalist pending ENT to see, then they are obligated by EMTALA to see the patient to stop the epistaxis (condition not stabilized until epistaxis stops). If they are admitted for abdominal pain and then develop epistaxis, EMTALA doesn't apply. On-call consultant isn't required to see the patient by CMS/EMTALA, but may be obligated to see the patient by hospital bylaws if so specified. The condition has to be present upon patient presentation in the ER for EMTALA to apply. Anything that develops afterwards that isn't a direct and proximate condition related to their presenting condition is not mandated by EMTALA.

 

[thegenius]

My prior comment reflects only the legal nature of our health care system, and the fact that doctors seemingly don't want to do much of anything unless their risk is low and they get paid enough to do it.

Putting in a rapid rhino is so easy to do, it doesn't require the skills of an ER doctor or even an ENT. Any doctor that has an MD or DO after their name should be OK soaking a rapid rhino in water or Afrin and sticking it into the nose and inflating it by a CC or two to stop bleeding.

ENT doesn't want to be bothered with this because it's simple to do by anyone and driving in, stopping the bleeding, writing a quick note and going home is not worth the few RVUs generated.

ER doesn't want to do it because we are working somewhere else, and it's something that other doctors should do.

Hospitalists don't want to do it because they are afraid of doing it and are afraid of litigation, and are overall just afraid of any procedure no matter how minor primarily because of legal stuff.

This whole concept is really ridiculous.

 

[Groove]

All of our surgical services get paid. I don't think I've ever worked at a community gig where ENT wasn't paid for call. Even the AAO-HNS has an official policy recommending and supporting paid call coverage. In fact, at my current gig, they renegotiated for additional money a few years back and the hospital balked, so they stopped providing coverage. We just recently got ENT coverage again after probably 4 years of no ENT. It was miserable. I can't blame them though. Most of the times we call them in, at least where I'm at, the pt's are uninsured or unable to pay and it turns out to be an uncompensated charity case for them. I don't mind nosebleeds though and I can understand that people are uncomfortable managing them that don't see them with the frequency that we do. Gotta watch the occasional old geezer that vagals down after packing/rhino. Now, I'd have a real problem having to run up to the floor to manage one of those. Luckily, I've only had to do that once for our family medicine residents who were panicking. We don't respond to much of anything from the ER at my current hospital which is an extremely nice perk (ICU handles 100% codes = GOLD).

Position Statement: Reimbursement for Taking Hospital Call

There is a growing crisis in Americas hospitals because of a shortage of both otolaryngologists and other on-call specialists. This crisis causes delays in patient care and may impact the quality of care provided to patients.

www.entnet.org

 

[Vandalia]

It's interesting that so much of the observed behavior in a health care system is driven around fear of litigation. Lawyers own our society.

If health care systems were protected against legal action we would have a more efficient and cheaper one.

Good for society, bad for us. The threat of a lawsuit is the only thing that keeps board certified physicians employed. If there is no downside, why would any hospital employ an EM residency grad? Or more specifically pay us more than they do FM working in a clinic?

 

[TooMuchResearch]

I had an anticoagulated old dude vagal himself down (too much blood in the stomach?). When he lost consciousness, his stomach of blood more or less exploded out of his mouth. He did fine with packing after that. Admitted to a hospital without ENT coverage for cardiac monitoring (wide complex bradycardia).

All of our surgical services get paid. I don't think I've ever worked at a community gig where ENT wasn't paid for call. Even the AAO-HNS has an official policy recommending and supporting paid call coverage. In fact, at my current gig, they renegotiated for additional money a few years back and the hospital balked, so they stopped providing coverage. We just recently got ENT coverage again after probably 4 years of no ENT. It was miserable. I can't blame them though. Most of the times we call them in, at least where I'm at, the pt's are uninsured or unable to pay and it turns out to be an uncompensated charity case for them. I don't mind nosebleeds though and I can understand that people are uncomfortable managing them that don't see them with the frequency that we do. Gotta watch the occasional old geezer that vagals down after packing/rhino. Now, I'd have a real problem having to run up to the floor to manage one of those. Luckily, I've only had to do that once for our family medicine residents who were panicking. We don't respond to much of anything from the ER at my current hospital which is an extremely nice perk (ICU handles 100% codes = GOLD).

Position Statement: Reimbursement for Taking Hospital Call

There is a growing crisis in Americas hospitals because of a shortage of both otolaryngologists and other on-call specialists. This crisis causes delays in patient care and may impact the quality of care provided to patients.

www.entnet.org

 

[thegenius]

Good for society, bad for us. The threat of a lawsuit is the only thing that keeps board certified physicians employed. If there is no downside, why would any hospital employ an EM residency grad? Or more specifically pay us more than they do FM working in a clinic?

Yea perhaps. Kind of a real downer if one looks at it that way. Sad...one way to summarize what you are suggesting is for us to make more money, we have to be under increasing risk and threat from lawyers and politics - and the pain and anguish that comes with all of that.

 

[Groove]

I had an anticoagulated old dude vagal himself down (too much blood in the stomach?). When he lost consciousness, his stomach of blood more or less exploded out of his mouth. He did fine with packing after that. Admitted to a hospital without ENT coverage for cardiac monitoring (wide complex bradycardia).

Nice, yeah those cases can give you a a new respect for innocuous nasal packing in the elderly.

 

[WilcoWorld]

Good for society, bad for us. The threat of a lawsuit is the only thing that keeps board certified physicians employed. If there is no downside, why would any hospital employ an EM residency grad? Or more specifically pay us more than they do FM working in a clinic?

Because they want their patients to receive the best care possible? Because good care delivered by conscientious docs is actually cheaper?

Nah, it's probly cuz we look good on billboards.

 

[TooMuchResearch]

I should specify, he had a 40 bpm junctional rhythm on arrival and felt like stink for about 3 minutes before he lost consciousness. He felt much better after that little episode of unconscious hematemesis and rhythm normalized. I warned him it could happen again with packing, and he was game but his daughter was a bit skittish.

Nice, yeah those cases can give you a a new respect for innocuous nasal packing in the elderly.