Review article: Patients who leave before care is completed: What does the legal duty to warn mean for emergency department clinicians?

Patients leave ED for a variety of reasons and at all stages of care. In Australian law, clinicians and health services owe a duty of care to people presenting to the ED for care, even if they have not yet entered a treatment space. There is also a positive duty to warn patients of material risks associated with their condition, proposed treatment(s), reasonable alternative treatment options and the likely effect of their healthcare decisions, including refusing treatment. This extends to a decision to leave the ED before care is completed. The form of that warning may vary based on what is known about the patient's condition and the associated risks at the time. Specific documentation of warnings given is essential.

End-of-life decision-making in the emergency department and intensive care unit: Health professionals' perspectives on and knowledge of the law in Queensland

OBJECTIVE

To investigate ED and intensive care unit healthcare professionals' perspectives and knowledge of the law that underpins end-of-life decision-making in Queensland, Australia.

METHODS

An online survey with questions about perspectives, perceived, and actual, knowledge of the law was distributed by the professional organisations of medical practitioners, nurses and social workers who work in Queensland EDs and intensive care units.

RESULTS

The survey responses of 126 healthcare professionals were included in the final analysis. Most respondents agreed that the law was relevant to end-of-life decision-making, but that clinician and family consensus mattered more than following the law. Generally, doctors' legal knowledge was higher than nurses'; however, there were significant gaps in the knowledge of all respondents about the operation of advance health directives in Queensland.

CONCLUSIONS

The legal framework that supports end-of-life decision-making for adults who lack decision-making capacity has been in place for more than two decades. Despite frequently being involved in making or enacting these decisions, gaps in the legal knowledge of healthcare professionals who work in EDs and intensive care units in Queensland are evident. Further research to better understand how to improve knowledge and application of the law is warranted.

[Liaison geriatrics with nursing homes in COVID time. A new coordination model arrived to stay]

Older people living in nursing homes fulfil the criteria to be considered as geriatric patients, but they often do not have met their health care needs. Current deficits appeared as a result of COVID-19 pandemic. The need to improve the coordination between hospitals and nursing homes emerged, and in Madrid it materialized with the implantation of Liaison Geriatrics teams or units at public hospitals. The Sociedad Española de Geriatría y Gerontología has defined the role of the geriatricians in the COVID-19 pandemic and they have given guidelines about prevention, early detection, isolation and sectorization, training, care homes classification, patient referral coordination, and the role of the different care settings, among others. These units and teams also must undertake other care activities that have a shortfall currently, like nursing homes-hospital coordination, geriatricians visits to the homes, telemedicine sessions, geriatric assessment in emergency rooms, and primary care and public health services coordination. This paper describes the concept of Liaison Geriatrics and its implementation at the Autonomous Community of Madrid hospitals as a result of COVID-19 pandemic. Activity data from a unit at a hospital with a huge number of nursing homes in its catchment area are reported. The objective is to understand the need of this activity in order to avoid the current fragmentation of care between hospitals and nursing homes. This activity should be consolidated in the future.

EMTALA: Testing the Good Faith Admission Requirement

The Fourth Circuit Court of Appeals' March 13, 2020 decision in Williams v. Dimension Health Corporation reintroduced scrutiny on the lesser-known mandate of The Emergency Medical Treatment and Active Labor Act (EMTALA) concerning good faith admission to the hospital. EMTALA was enacted by Congress in 1986 to prevent patient dumping by prohibiting hospitals with emergency departments from refusing to provide emergency medical treatment to patients unable to pay for treatment, and prohibiting the transfer of those patients before their emergency medical conditions are stabilized. The reach of EMTALA ends when a patient is admitted and consequently becomes an inpatient, because then the hospital believes the patient would benefit from admission, and discharge and transfer would not occur as outlined in EMTALA. This paper examines the analysis of this mandate in Williams v. Dimension Health Corporation, and closely investigates one particular aspect of it: that admission must be made in good faith; otherwise, application of EMTALA's screening and stabilization requirements has not yet terminated, and hospitals can still be found culpable.

Learning the developments in EMTALA jurisprudence through the lens of John West's "case law update"

This article covers three recurring issues concerning the federal law known as the Emergency Medical Treatment and Labor Act (EMTALA) that keep popping up in John West's Case Law Update case updates, and consistently bedevil hospital risk managers. First, what exactly constitutes an "appropriate" medical screening examination; second, when is a patient actually "stabilized' under EMTALA; and third, does the EMTALA obligation really "disappear" when a patient is admitted to the hospital? The editors wanted to analyze topics that challenge the courts to "get it right" on the law and that drive risk managers crazy. EMTALA is the "poster child" for such a topic.

Penalties for Emergency Medical Treatment and Labor Act Violations Involving Obstetrical Emergencies

INTRODUCTION

The Emergency Medical Treatment and Labor Act (EMTALA) was intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (ED). While controversies exist regarding the scope of the law, there is no question that EMTALA applies to active labor, a key tenet of the statute and the only medical condition - labor - specifically included in the title of the law. In light of rising maternal mortality rates in the United States, further exploration into the state of emergency obstetrical (OB) care is warranted. Understanding civil monetary penalty settlements levied by the Office of the Inspector General (OIG) related to EMTALA violations involving labor and other OB emergencies will help to inform the current state of access to and quality of OB emergency care.

METHODS

We reviewed descriptions of all EMTALA-related OIG civil monetary penalty settlements from 2002-2018. OB-related cases were identified using keywords in settlement descriptions. We described characteristics of settlements including the nature of the allegation and compared them with non-OB settlements.

RESULTS

Of 232 EMTALA-related OIG settlements during the study period, 39 (17%) involved active labor and other OB emergencies. Between 2002 and 2018 the proportion of settlements involving OB emergencies increased from 17% to 40%. Seven (18%) of these settlements involved a pregnant minor. Most OB cases involved failure to provide screening exam (82%) and/or stabilizing treatment (51%). Failure to arrange appropriate transfer was more common for OB (36%) compared with non-OB settlements (21%) (p = 0.041). Fifteen (38%) involved a provider specifically directing a pregnant woman to proceed to another hospital, typically by private vehicle.

CONCLUSION

Despite inclusion of the term "labor" in the law's title, one in six settlements related to EMTALA violations involved OB emergencies. One in five settlements involved a pregnant minor, indicating that providers may benefit from education regarding obligations to evaluate and stabilize minors absent parental consent. Failure to arrange appropriate transfer was more common among OB settlements. Findings suggesting need for providers to understand EMTALA-specific requirements for appropriate transfer and for EDs at hospitals without dedicated OB services to implement policies for evaluation of active labor and protocols for transfer when indicated.

The effect of breed-specific dog legislation on hospital treated dog bites in Odense, Denmark-A time series intervention study

As dog bite injuries are a considerable problem in modern society, in order to reduce such injuries, breed-specific legislation has been introduced in a number of countries. Whilst many studies have shown a lack of effect with such legislation, the commonly used methodology is known to be flawed. Therefore, the aim of this study is to investigate the effect of the Danish breed-specific legislation on the number of dog bite injuries using more credible methods. A time series intervention method was used on a detailed dataset from Odense University Hospital, Denmark, regarding dog bite injuries presented to the emergency department. The results indicate that banning certain breeds has a highly limited effect on the overall levels of dog bite injuries, and that an enforcement of the usage of muzzle and leash in public places for these breeds also has a limited effect. Despite using more credible and sound methods, this study supports previous studies showing that breed-specific legislation seems to have no effect on dog bite injuries. In order to minimise dog bite injuries in the future, it would seem that other interventions or non-breed-specific legislation should be considered as the primary option.

[Emergency nurse, a speciality whose name says it all?]

Proposal no. 10 in French Senate information report no. 685, drawn up by the Social Affairs Commission on hospital emergency departments, opens the debate regarding the creation of an emergency nursing speciality. Does this represent progress for the profession or an inadapted measure? The complex situation of emergency departments raises the need for methodological thinking on this subject.

A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina

BACKGROUND

In response to increasing opioid overdoses, US prevention efforts have focused on prescriber education and supply, demand and harm reduction strategies. Limited evidence informs which interventions are effective. We evaluated Project Lazarus, a centralised statewide intervention designed to prevent opioid overdose.

METHODS

Observational intervention study of seven strategies. 74 of 100 North Carolina counties implemented the intervention. Dichotomous variables were constructed for each strategy by county-month. Exposure data were: process logs, surveys, addiction treatment interviews, prescription drug monitoring data. Outcomes were: unintentional and undetermined opioid overdose deaths, overdose-related emergency department (ED) visits. Interrupted time-series Poisson regression was used to estimate rates during preintervention (2009-2012) and intervention periods (2013-2014). Adjusted IRR controlled for prescriptions, county health status and time trends. Time-lagged regression models considered delayed impact (0-6 months).

RESULTS

In adjusted immediate-impact models, provider education was associated with lower overdose mortality (IRR 0.91; 95% CI 0.81 to 1.02) but little change in overdose-related ED visits. Policies to limit ED opioid dispensing were associated with lower mortality (IRR 0.97; 95% CI 0.87 to 1.07), but higher ED visits (IRR 1.06; 95% CI 1.01 to 1.12). Expansions of medication-assisted treatment (MAT) were associated with increased mortality (IRR 1.22; 95% CI 1.08 to 1.37) but lower ED visits in time-lagged models.

CONCLUSIONS

Provider education related to pain management and addiction treatment, and ED policies limiting opioid dispensing showed modest immediate reductions in mortality. MAT expansions showed beneficial effects in reducing ED-related overdose visits in time-lagged models, despite an unexpected adverse association with mortality.

Provider and Practice Factors Associated With Emergency Physicians' Being Named in a Malpractice Claim

STUDY OBJECTIVE

We examine the association between emergency physician characteristics and practice factors with the risk of being named in a malpractice claim.

METHODS

We used malpractice claims along with provider, operational, and jurisdictional data from a national emergency medicine group (87 emergency departments [EDs] in 15 states from January 1, 2010, to June 30, 2014) to assess the relationship between individual physician and practice variables and being named in a malpractice claim. Individual and practice factors included years in practice, emergency medicine board certification, visit admission rate, relative value units generated per hour, total patients treated as attending physician of record, working at multiple facilities, working primarily overnight shifts, patient experience data percentile, and state malpractice environment. We assessed the relationship between emergency physician and practice variables and malpractice claims, using logistic regression.

RESULTS

Of 9,477,150 ED visits involving 1,029 emergency physicians, there were 98 malpractice claims against 90 physicians (9%). Increasing total number of years in practice (adjusted odds ratio 1.04; 95% confidence interval 1.02 to 1.06) and higher visit volume (adjusted odds ratio 1.09 per 1,000 visits; 95% confidence interval 1.05 to 1.12) were associated with being named in a malpractice claim. No other factors were associated with malpractice claims.

CONCLUSION

In this sample of emergency physicians, 1 in 11 were named in a malpractice claim during 4.5 years. Total number of years in practice and visit volume were the only identified factors associated with being named, suggesting that exposure to higher patient volumes and longer practice experience are the primary contributors to malpractice risk.

Issues affecting health professionals during and after catastrophic earthquakes in Van-Turkey

OBJECTIVE

To assess physical and psycho-social problems faced by health professionals, and to analyse the ethical, legal and triage dimensions of disaster medical services.

METHODS

The descriptive study was conducted from November 2011 to March 2012 and comprised health professionals from two hospitals of Van, Turkey A specific questionnaire was designed and interviews were conducted face to face. SPSS 13 was used for statistical analysis.

RESULTS

Of the 430 health professionals who had experienced one or more earthquakes and were part of the study, 225(52.3%) were nurses and 205(47.7%) were doctors. There were 224(52%) women and 206(48%) men. Besides, 206(48) were below 31 years of age. Overall, 193(44.9%) participants experienced chaos, 83(19.3%) panic and fear, and 129(30%) despair. Only 20(4.7%) of them lived at home, while others lived in tents, containers, hospitals or cars during the emergency and continued to provide services despite social, economic and psychological problems. Triage was preferred by 339(78.8%) of the respondents.

CONCLUSIONS

Problems of health professionals were multi-dimensional and addressing them would make service delivery more effective.

[Alcoholism and regional strategy and collaboration]

The most part of an estimated alcohol dependence syndrome person has only a medical treatment of a complication in primary care medicine in Japan, and only about 5% is related to treatment. Therefore many intoxicated persons go to an emergency hospital, and a staff takes an excessive burden. Cooperation of various organizations is important to the police, fire fighting, polity and a self-help meeting as well as between the medical agencies to link non-healer to treatment. The law which does the health problem measure by alcohol behind schedule compared with foreign countries in 2013 is established, and it' s expected that cooperation will be developed from now on.

Exceeding the Legal Time Limits for Involuntary Mental Health Examinations: A Study of Emergency Department Delays

This study addressed delays to involuntary mental health examinations experienced by individuals in emergency departments (EDs). Florida statute specifies that involuntary mental health examinations shall take place only at state-designated facilities "without unnecessary delay"-no longer than 12 h until transfer-for individuals in hospital EDs. Individuals in EDs needing involuntary mental health examinations sometimes wait for admission to inpatient units because of unavailability of mental health services. Data collectors at two hospitals reviewed the records of 170 randomly selected ED patients requiring involuntary mental health examinations. Nearly one-half (48.8%) of participants waited longer than the 12-h maximum allowed by Florida law for transfer to an authorized facility. Factors that associated with prolonged waits were being male, increased age, being a Medicare beneficiary, and being intoxicated. State agencies responsible for the regulation of hospitals and mental health facilities should use this data and engage front-line caregivers to identify statutory remedies.

Medicine as a Public Calling

The debate over how to tame private medical spending tends to pit advocates of government-provided insurance--a single-payer scheme--against those who would prefer to harness market forces to hold down costs. When it is mentioned at all, the possibility of regulating the medical industry as a public utility is brusquely dismissed as anathema to the American regulatory tradition. This dismissiveness, however, rests on a failure to appreciate just how deeply the public utility model shaped health law in the twentieth century-- and how it continues to shape health law today. Closer economic regulation of the medical industry may or may not be prudent, but it is by no means incompatible with our governing institutions and political culture. Indeed, the durability of such regulation suggests that the modern embrace of market-based approaches in the medical industry may be more ephemeral than it seems.

The effect of malpractice reform on emergency department care

BACKGROUND

Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice.

METHODS

Using a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions.

RESULTS

For eight of the nine state-outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges.

CONCLUSIONS

Legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates. (Funded by the Veterans Affairs Office of Academic Affiliations and others.).

Preparing for section 501(r)

Steps hospitals should take to prepare for Section 501(r) requirements include the following: Prepare the board for its role in approving updated financial assistance, billing and collections, and emergency medical care policies. Revisit financial assistance policy eligibility requirements. Conduct a policy gap analysis. Review how the current financial assistance policy is publicized and make adjustments where necessary.

The rise of emergency medicine in the sixties: paving a new entrance to the house of medicine

Emergency medicine evolved into a medical specialty in the 1960s under the leadership of physicians in small communities across the country. This paper uses three case studies to investigate the political, societal, and local factors that propelled emergency medicine along this path. The case studies-Alexandria Hospital, Hartford Hospital, and Yale-New Haven Hospital-demonstrate that the changes in emergency medicine began at small community hospitals and later spread to urban teaching hospitals. These changes were primarily a response to public demand. The government, the American public, and the medical community brought emergency medical care to the forefront of national attention in the sixties. Simultaneously, patients' relationships with their general practitioners dissolved. As patients started to use the emergency room for non-urgent health problems, emergency visits increased astronomically. In response to rising patient loads and mounting criticism, hospital administrators devised strategies to improve emergency care. Drawing on hospital archives, oral histories, and statistical data, I will argue that small community hospitals' hiring of full-time emergency physicians sparked the development of a new specialty. Urban teaching hospitals, which established triage systems and ambulatory care facilities, resisted the idea of emergency medicine and ultimately delayed its development.

About a case of missed diagnosis of a post-traumatic aneurysm in the ulnar artery. Medical-legal aspects in respect to the professional liability

Compartment syndrome of the left hand from a late diagnosed post-traumatic ulnar artery pseudoaneurysm. We report the case of 27 years old boy with a tipping and cutting wound on his left wrist, generating an ulnar artery pseudoaneurysm, that was late diagnosed, and therefore complicated by a compartment syndrome in the wrist. Immediately after the trauma the subject went to the emergency room where the severity of the injury was undestimated; in fact, it was sutured and medicated, without further investigation. When he went to the same hospital for the second time, symptoms (pulsatile mass, redness and irritation of the skin) were interpreted as an infectious process and treated in an incongruous way. Then, when he went to another hospital in which imaging studies (ultrasound) were performed, the pseudo- aneurysm of the ulnar artery was diagnosed and surgically treated. The delay in diagnosis led to a compartment syndrome that is still appreciable as a sensory-motor deficit of the hand, especially of the fourth and fifth finger. This pseudo- aneurysm complication and its debilitating outcomes are known in literature, so the diagnostic delay makes the sanitary staff guilty of the suffered damage.

Incidence and predictors of neck and widespread pain after motor vehicle collision among US litigants and nonlitigants

Debate continues regarding the influence of litigation on pain outcomes after motor vehicle collision (MVC). In this study we enrolled European Americans presenting to the emergency department (ED) in the hours after MVC (n=948). Six weeks later, participants were interviewed regarding pain symptoms and asked about their participation in MVC-related litigation. The incidence and predictors of neck pain and widespread pain 6weeks after MVC were compared among those engaged in litigation (litigants) and those not engaged in litigation (nonlitigants). Among the 859 of 948 (91%) participants completing 6-week follow-up, 711 of 849 (83%) were nonlitigants. Compared to nonlitigants, litigants were less educated and had more severe neck pain and overall pain, and a greater extent of pain at the time of ED evaluation. Among individuals not engaged in litigation, persistent pain 6weeks after MVC was common: 199 of 711 (28%) had moderate or severe neck pain, 92 of 711 (13%) had widespread pain, and 29 of 711 (4%) had fibromyalgia-like symptoms. Incidence of all 3 outcomes was significantly higher among litigants. Initial pain severity in the ED predicted pain outcomes among both litigants and nonlitigants. Markers of socioeconomic disadvantage predicted worse pain outcomes in litigants but not nonlitigants, and individual pain and psychological symptoms were less predictive of pain outcomes among those engaged in litigation. These data demonstrate that persistent pain after MVC is common among those not engaged in litigation, and provide evidence for bidirectional influences between pain outcomes and litigation after MVC.

ED, heal thyself

Emergency department (ED) wait times have continued to worsen despite receiving considerable attention for more than 2 decades and despite the availability of a variety of methods to restructure care in a more streamlined fashion. This article offers an economic framework that abstracts away from the details of operations research to understand the fundamental disincentives to improving wait times. Hospitals that reduce wait times are financially penalized if they must provide more uncompensated care as a result. Pending changes under the Patient Protection and Affordable Care Act are considered. We find that the likely effect of the Patient Protection and Affordable Care Act's insurance expansion is to reduce this penalty for improving ED wait times. Consequently, mandating adoption of solutions to ED crowding may be unnecessary and counterproductive. If the insurance expansion is insufficient to fully solve the problem, the hospital value-based purchasing initiative should adopt wait times as a goal in its next iteration.