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.