Drunk healthcare professional checks into the ER immediately after work. What would you do?

[Zebra Hunter]

Had this case several months ago of a guy that got off from work as an OR nurse and came directly to the hospital, per him, for epigastric pain. He works at another hospital within our system. He has a history of pancreatitis due to “unknown cause”. He seems off and I suspect he is drunk. His alcohol level is 300 and lipase is markedly elevated. I inform him that he is drunk, and alcoholism is likely the cause of his recurrent pancreatitis. He of course says that’s impossible and must still be in his system from the past weekend (4 days ago), which I tell him is impossible.

What would y’all do? Ignore it and admit him due to concerns regarding HIPAA? Report him to the nursing board after admitting him? Something else?

I decided to ask my charge to call the admin on-call to discuss what the best course of action is, as this is a public health concern. They decided to make a formal complaint to the nursing board and inform the patient’s nursing manager. I made none of the calls myself and just let admin handle it.

---

Members don't see this ad.

 

[bravotwozero]

Looks like you did the right thing, and handled it perfectly. You got everyone else to make the uncomfortable phone calls.

 

[deleted480308]

Yeah, it’s a patient safety issue, glad you reported

 

[southerndoc]

You asked the charge nurse about something not related to patient care. This can be spun into a valid HIPAA complaint. You open yourself up to liability for doing so since HIPAA only allows communication with other providers relating to patient care. This is more of a professional issue.

Do you call police to report a patient involved in an MVC was intoxicated so they can come draw a BAL? Drunk drivers are threats to public safety.

Having said that, I think you did the right thing professionally even if it was a HIPAA violation. Even though you didn't personally report it, you were a complicit party to it by involving the charge nurse. It would be different if he/she found out about the alcohol intoxication through chart perfusing.

There may be state laws that come into being here that require you to report this to a nursing board. If that is the case, then you are off the hook from a HIPAA standpoint.

Your charge nurse may be in more trouble here though if the patient is fired for his/her actions. Most state laws require someone who is drug dependent to be offered rehab instead of termination. You can only terminate someone if they refuse rehab -- even if it jeopardizes patient safety. I've known of nurses get caught injecting Dilaudid on duty and they came back to work a few months later after rehab.

 

[Zebra Hunter]

You asked the charge nurse about something not related to patient care. This can be spun into a valid HIPAA complaint. You open yourself up to liability for doing so since HIPAA only allows communication with other providers relating to patient care. This is more of a professional issue.

Do you call police to report a patient involved in an MVC was intoxicated so they can come draw a BAL? Drunk drivers are threats to public safety.

Having said that, I think you did the right thing professionally even if it was a HIPAA violation. Even though you didn't personally report it, you were a complicit party to it by involving the charge nurse. It would be different if he/she found out about the alcohol intoxication through chart perfusing.

There may be state laws that come into being here that require you to report this to a nursing board. If that is the case, then you are off the hook from a HIPAA standpoint.

Your charge nurse may be in more trouble here though if the patient is fired for his/her actions. Most state laws require someone who is drug dependent to be offered rehab instead of termination. You can only terminate someone if they refuse rehab -- even if it jeopardizes patient safety. I've known of nurses get caught injecting Dilaudid on duty and they came back to work a few months later after rehab.

Yeah, this is kind of what I thought would be the case, but I also won't lose sleep if the nurse decides to file a suit against us. There is basically no case law for this scenario that I am aware of, and I have a hard time imagining anyone siding with the drunk on the job nurse over healthcare professionals making an in good faith report.

 

[Birdstrike]

Had this case several months ago of a guy that got off from work as an OR nurse and came directly to the hospital, per him, for epigastric pain. He works at another hospital within our system. He has a history of pancreatitis due to “unknown cause”. He seems off and I suspect he is drunk. His alcohol level is 300 and lipase is markedly elevated. I inform him that he is drunk, and alcoholism is likely the cause of his recurrent pancreatitis. He of course says that’s impossible and must still be in his system from the past weekend (4 days ago), which I tell him is impossible.

What would y’all do? Ignore it and admit him due to concerns regarding HIPAA? Report him to the nursing board after admitting him? Something else?

I decided to ask my charge to call the admin on-call to discuss what the best course of action is, as this is a public health concern. They decided to make a formal complaint to the nursing board and inform the patient’s nursing manager. I made none of the calls myself and just let admin handle it.

I don't know if this is a HIPAA violation or not, but I can't say you did the wrong thing. You're more likely to have save a life in this patient encounter (either the patient, a patient of your patient or those who share the roads with him) than with the vast majority of patient encounters. Lose no sleep over this one.

 

[cyanide12345678]

Had this case several months ago of a guy that got off from work as an OR nurse and came directly to the hospital, per him, for epigastric pain. He works at another hospital within our system. He has a history of pancreatitis due to “unknown cause”. He seems off and I suspect he is drunk. His alcohol level is 300 and lipase is markedly elevated. I inform him that he is drunk, and alcoholism is likely the cause of his recurrent pancreatitis. He of course says that’s impossible and must still be in his system from the past weekend (4 days ago), which I tell him is impossible.

What would y’all do? Ignore it and admit him due to concerns regarding HIPAA? Report him to the nursing board after admitting him? Something else?

I decided to ask my charge to call the admin on-call to discuss what the best course of action is, as this is a public health concern. They decided to make a formal complaint to the nursing board and inform the patient’s nursing manager. I made none of the calls myself and just let admin handle it.

The only question is how do you know he didn't take a detour, get drunk, then come in to your ER? Are you absolutely certain that he was hammered while at work?

Though you definitely did the right thing in my opinion. I probably would have talked with legal first about this.

 

[MechEDoc]

I think going through legal (instead of admin on call) would have been a little more defensible, However, I can't imagine anyone would want to make an issue of what you did.

 

[clibby]

This should not be a HIPAA violation. Assuming this was done in good faith, there is a specific carve out in 45 CFR § 164.512 for reporting to health oversight agencies.

 

[Birdstrike]

The only question is how do you know he didn't take a detour, get drunk, then come in to your ER? Are you absolutely certain that he was hammered while at work?

Though you definitely did the right thing in my opinion. I probably would have talked with legal first about this.

In the OP he says the patient told him he left work and went right to the ED with no stop. If he had made a stop at the local watering hole first, that might have been a detail to tell the doc.

 

[Groove]

I think you handled that well. I would have probably done the same. Regardless of HIPAA concerns, I doubt that there's any court in the land that would find fault with an ER physician trying to do the right thing with a nurse or other healthcare professional found intoxicated at work where there's legitimate concerns for pt safety under their care.

 

[Tenk]

You asked the charge nurse about something not related to patient care. This can be spun into a valid HIPAA complaint. You open yourself up to liability for doing so since HIPAA only allows communication with other providers relating to patient care. This is more of a professional issue.

Do you call police to report a patient involved in an MVC was intoxicated so they can come draw a BAL? Drunk drivers are threats to public safety.

Having said that, I think you did the right thing professionally even if it was a HIPAA violation. Even though you didn't personally report it, you were a complicit party to it by involving the charge nurse. It would be different if he/she found out about the alcohol intoxication through chart perfusing.

There may be state laws that come into being here that require you to report this to a nursing board. If that is the case, then you are off the hook from a HIPAA standpoint.

Your charge nurse may be in more trouble here though if the patient is fired for his/her actions. Most state laws require someone who is drug dependent to be offered rehab instead of termination. You can only terminate someone if they refuse rehab -- even if it jeopardizes patient safety. I've known of nurses get caught injecting Dilaudid on duty and they came back to work a few months later after rehab.

My state actually does require us to report to police anyone involved in an accident who is under the influence of alcohol and it is a wonderful law that should be universal.

 

[DrDrummer]

I've had this happen with an on-call provider (paid to be on-call, only coverage for given service line which was responsible for coverage of things that could actually be emergencies) who showed up drunk with a superficial injury. I found the specific policies involved in suspected intoxication / impairment and applied them with help from the administrator on call. They called a hospital lawyer given that the person was on home call to ensure we could still apply the relevant policy. We followed the policies by the book and it all worked out fine. Ugh. Not fun but important and I think the right thing to do.

 

[Lexdiamondz]

The only question is how do you know he didn't take a detour, get drunk, then come in to your ER? Are you absolutely certain that he was hammered while at work?

Though you definitely did the right thing in my opinion. I probably would have talked with legal first about this.

That's a hard argument to make in todays era where everything has an electronic paper trail. You can tell when people swipe out with their badges, or when they last logged into the EMR, and if those times dont add up to when they presented to the ED then OP may be able to defend themselves by arguing the nurse was tipsy at work.

More tellingly, to be able to get to an EtOH level of 300 rapidly with only mild signs of intoxication suggests that the nurse in question is almost definitely an alcoholic. Most normal people are pretty sloshed at 300.

 

[Vandalia]

There is an exception in HIPAA that allows for disclosures to state healthcare licensing boards/agencies..

A covered entity may disclose protected health information to a health oversight agency for oversight activities authorized by law, including audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight of: 45 CFR § 164.512(d)

There has been at least one court case that dealt with a scenario that was somewhat close to what was discussed here, and the disclosure was held not to violate HIPAA. However, this will depend on the specifics of state law and the information disclosed must be minimized. This is something you don't want to jump into on your own but it is best to get the lawyers involved. As was done in this case.

 

[wareagle726]

In my mind at the end of the day if you hadn't reported it and there had been a bad outcome from this person being intoxicated down the line in a surgery I think you would be in deeper you know what. I think I would have taken a similar approach.

 

[Fart Daddy Smooth]

The only question is how do you know he didn't take a detour, get drunk, then come in to your ER? Are you absolutely certain that he was hammered while at work?

Though you definitely did the right thing in my opinion. I probably would have talked with legal first about this.

I've seen this happen 5 times now and the state board was notified exactly once. Granted, it was for narc diversion but still - it places the hospital under a level of scrutiny that is generally unwanted. Narc record audits, etc. One RN underwent rehab and returned, the others left. No idea what happened to them, still working I presume.

Gotta cover your behind by notifying hospital admin of course but I wouldn't be surprised if they deem this too thorny an issue to pursue further. What a world we live in!

 

[Fart Daddy Smooth]

It doesn’t matter if the hospital gets unwanted attention. It’s wrong to let anyone whether it is a tech, nurse or physician work while impaired. It’s a patient safety issue. I’d go through the proper channels every time to make sure this is reported all the way up. I’m not worried about the hospital viewing as a thorny issue as I wouldn’t want to work for a hospital that wouldn’t deal with substance abuse issues or narcotic diversion appropriately. Most do the right thing.

Of course! But as we so often see, patient safety may take a back seat to hospital profitability. All we can do is report it through the proper channels and hopefully the individual gets the help they need

 

[DocEspana]

I did once treat a prominent ED physician for alcohol intoxication and part of the workup was making sure that he didnt just come from shift like that (did it in a hipaa compliant way). He didn't. He was just partying way too hard by my facility. I'm not sure what I would have done if he had just come off of shift since its not provable that he didnt just chug a bottle of vodka as he walked out the door.... but I knew it would have been something that would have needed some addressing/looking into if it did happen.

So applying my past logic to what you did - it seems like you did the right thing.

 

[deleted171991]

First of all, I apologize for reopening an old topic, but I think there are some egregious mistakes in here. The road to hell is paved with good intentions.

I'm just an anesthesiologist-intensivist, not a lawyer or HIPAA expert, but I honestly don't remember any part of HIPAA that allows physician to inform a patient's employer about a patient's health, unless there is an IMMEDIATE risk to a third-party (e.g. surgeon comes drunk to ER as a patient, and plans to perform surgery immediately after his ER visit).

In this case, the patient was off-duty. It doesn't really matter how long he had been off-duty (if he has a big bottle of whisky the second he finishes his shift, it's his business). He did not admit to drinking post-duty, maybe because he had been drinking during duty hours, or maybe he did not want to discuss his alcoholism with the EM physician. He did not want a sermon; he wanted his pain gone. It doesn't really matter why; he's the patient, and he has a right to privacy. He's also a licensed healthcare professional, I get it, but that still doesn't mean that he has no legal protections.

The OP was suspicious that the patient had been drinking during his duty hours. Fine. What does the law say, in situations like this? As Vandalia said:

There is an exception in HIPAA that allows for disclosures to state healthcare licensing boards/agencies..

A covered entity may disclose protected health information to a health oversight agency for oversight activities authorized by law, including audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight of: 45 CFR § 164.512(d)

If one clicks on the "health oversight agency" link, one gets:

"Health oversight agency means an agency or authority of the United States, a State, a territory, a political subdivision of a State or territory, or an Indian tribe, or a person or entity acting under a grant of authority from or contract with such public agency, including the employees or agents of such public agency or its contractors or persons or entities to whom it has granted authority, that is authorized by law to oversee the health care system (whether public or private) or government programs in which health information is necessary to determine eligibility or compliance, or to enforce civil rights laws for which health information is relevant."

A hospital system is NOT a health oversight agency.

Translation: if suspicious, the OP should have reported the patient to the state nursing board, department of public health etc. If in doubt, s/he should have asked the hospital's legal counsel, not the supervisory chain. A supervisor does not have either legal training or a patient-doctor relationship. There was NO reason to share the patient's PHI with the supervisor/administrator. Public health concerns should be shared with public health oversight agencies.

So this was a huge breach of HIPAA. On top of that, the OP was unwise to post the story on a public forum, meaning that, if the nurse finds it, he may realize that his employment problems were due to a HIPAA breach. I would be surprised if he didn't sue for damages, even risking a Streisand effect. The OP may even suffer harm to his/her medical license, and federal penalties.

I do respect the OP's intent to prevent harm, but I doubt this was the correct solution.

 

[Oligodinero]

First of all, I apologize for reopening an old topic, but I think there are some egregious mistakes in here. The road to hell is paved with good intentions.

I'm just an anesthesiologist-intensivist, not a lawyer or HIPAA expert, but I honestly don't remember any part of HIPAA that allows physician to inform a patient's employer about a patient's health, unless there is an IMMEDIATE risk to a third-party (e.g. surgeon comes drunk to ER as a patient, and plans to perform surgery immediately after his ER visit).

In this case, the patient was off-duty. It doesn't really matter how long he had been off-duty (if he has a big bottle of whisky the second he finishes his shift, it's his business). He did not admit to drinking post-duty, maybe because he had been drinking during duty hours, or maybe he did not want to discuss his alcoholism with the EM physician. He did not want a sermon; he wanted his pain gone. It doesn't really matter why; he's the patient, and he has a right to privacy. He's also a licensed healthcare professional, I get it, but that still doesn't mean that he has no legal protections.

The OP was suspicious that the patient had been drinking during his duty hours. Fine. What does the law say, in situations like this? As Vandalia said:

If one clicks on the "health oversight agency" link, one gets:

"Health oversight agency means an agency or authority of the United States, a State, a territory, a political subdivision of a State or territory, or an Indian tribe, or a person or entity acting under a grant of authority from or contract with such public agency, including the employees or agents of such public agency or its contractors or persons or entities to whom it has granted authority, that is authorized by law to oversee the health care system (whether public or private) or government programs in which health information is necessary to determine eligibility or compliance, or to enforce civil rights laws for which health information is relevant."

A hospital system is NOT a health oversight agency.

Translation: if suspicious, the OP should have reported the patient to the state nursing board, department of public health etc. If in doubt, s/he should have asked the hospital's legal counsel, not the supervisory chain. A supervisor does not have either legal training or a patient-doctor relationship. There was NO reason to share the patient's PHI with the supervisor/administrator. Public health concerns should be shared with public health oversight agencies.

So this was a huge breach of HIPAA. On top of that, the OP was unwise to post the story on a public forum, meaning that, if the nurse finds it, he may realize that his employment problems were due to a HIPAA breach. I would be surprised if he didn't sue for damages, even risking a Streisand effect. The OP may even suffer harm to his/her medical license, and federal penalties.

I do respect the OP's intent to prevent harm, but I doubt this was the correct solution.

You make a good point. The inebriation was not discovered while the RN was on the clock. If they suspected impairment while the nurse was on duty, that's a whole other ball game. Certainly if a physician or nurse is found impaired OTJ, you are supposed to immediately notify the department chair, hospital admin so they can relieve the person from duty/prevent patient harm. This was most certainly not the case.