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Hospital diversion scheme draws ire of national ED organizations
In face of controversy, hospital might reconsider its policy
Several EDs across the country have initiated policies to encourage patients who don't face "true" emergencies to seek care elsewhere in the community and to find "medical homes," but none have been met with the outrage that descended upon the University of Chicago Medical Center recently. The Chicago Tribune reported that under a new policy, the hospital was "escalating steps to direct these consumers elsewhere, which it says will allow it to focus on treating the sickest of patients."1
Reaction from within the industry was swift and uncompromising. In a prepared statement, leaders of the American College of Emergency Physicians (ACEP) said the university was "dangerously close" to a "patient-dumping" policy that would violate the Emergency Medical Treatment and Labor Act (EMTALA). ACEP said that several emergency physicians and the ED director resigned over the new policy.
The American Academy of Emergency Medicine (AAEM) said the University of Chicago should "re-evaluate its triage and screening examination policies."
As ED Management went to press, an internal hospital memo indicated the facility was, indeed, "reconsidering" its policy,2 but ACEP and AEEM leaders remained skeptical. What's more, they say, such a re-evaluation would not negate some of the actions already taken. They also expressed concern that other facilities, facing growing financial pressures, might consider similar actions.
"It's good that they're listening to public constructive criticism, and perhaps even listening to their own ED physicians and nurses, whereas initially this was done without any input from clinical people," notes Larry D. Weiss, MD, JD, FAAEM, president of the AAEM, a professor of emergency medicine at the University of Maryland, Baltimore, and an attending ED physician at the University of Maryland Medical Center, also in Baltimore. "Several of our members, who work there, said they were not considered at all — that the policy was developed by administrative personnel," he says. Such an approach is tantamount to "changing the way the operating room works without consulting the surgeons," Weiss adds.
Weiss' objections extend to the new triage policy itself. "It's our understanding that if, during the screening exam, the physician determines the patient to be stable, they are directed to discharge them," he says. "But there are many stable patients who require admission, and the idea that they would turn away stable patients violates national standards of practice." For example, Weiss offers, a patient with a gallstone could be in a lot of pain but not have an infection, or someone with pneumonia might have stable vital signs. "Where do you draw the line?" he asks.
What the University of Chicago was doing went beyond what many other facilities have done, says Sandra Schneider, MD, an ACEP vice president. "What they did was, in order to maintain their financial status, they looked at the types of patients that added dollars to the hospital and made inpatient beds available to them while cutting down on the number of beds available to regular emergency treatment," says Schneider, who also is a professor of emergency medicine at the University of Rochester (NY) and an attending ED physician at Strong Memorial Hospital, also in Rochester.
Schneider says such a policy might not violate EMTALA, as long as the patients who are diverted don't have an emergency medical condition. However, there is a moral obligation to see them, she says. Schneider argues that most of these patients are not 'taking advantage' of the ED, which many assert is the case. "Our literature shows us that many of these people do not go on to get treatment," she says. "Those who choose to come to the ED often do so because there is no other option, either there are no clinics available, or those that are available are not open at the times they can get there."
As for the latest news about the hospital, "we do not know what they have come up with, although we're happy they are reconsidering the policy," says Schneider, who adds, "We'd be glad to meet with them and talk about it."
For more information on policies to address overcrowding and financial pressures, contact:
Hospital's plan — a bridge too far?
While it's true that many hospitals and EDs have instituted policies that seek to encourage nonurgent patients to find other medical "homes," the policy recently adopted at the University of Chicago Medical Center goes a bit farther than most, says Sandra Schneider, MD, vice president of the American College of Emergency Physicians.
"Many hospitals are doing something similar, but perhaps not as overt or as obvious," says Schneider, who also is a professor of emergency medicine at the University of Rochester (NY) and an attending ED physician at Strong Memorial Hospital in Rochester. "Many, for example, will choose to admit patients who have surgical needs to the OR over those from the ED, if there is one bed left in the hospital." She also has seen hospitals continue to take transfer patients even when the facility is full and patients are waiting in the ED, "because transfers usually pay better, have insurance more often, and have more complex issues," Schneider says.
Where the University of Chicago was a bit more overt about it, she asserts, is they began to shrink beds available to patients and the size of the ED, "which artificially reduces your ability to take in patients who cannot pay. It's one way to make sure you do not get those types of patients." What's more, such an approach is based on a misconception, says Michael Frank, MD, JD, FACEP, FCLM, general counsel and director of risk management for Emergency Medicine Physicians Management Group, in Canton, OH. "Editorial in the Chicago Tribune to support this policy cited average costs of $1,200 for an ED visit to demonstrate that the hospital can't afford nonurgent visits," he notes. "That may be what they charge, but that's not what the visit costs the hospital."
Hospitals, he notes, have many fixed costs, including utilities and salaries. "What it costs to treat someone with a sore throat is trivial," Frank says. "If you divert that patient, you may save $20, not $1,200."
For more information on policies directing non-urgent patients to other facilities, contact:
Beware of EMTALA, warns legal expert
Hospitals and EDs that institute policies similar to the recent approach instituted at the University of Chicago Medical Center would do well to consider that they may be in violation of the Emergency Medical Treatment and Labor Act (EMTALA), warns Michael Frank, MD, JD, FACEP, FCLM, general counsel and director of risk management for Emergency Medicine Physicians (EMP) Management Group in Canton, OH.
"You can form a system that will result in ED patients going elsewhere, once it has been determined they do not have an emergency medical condition that will comply with EMTALA, but it's very difficult to do that — and very hazardous — because the standard that is used will be retroactively applied," he says.
EMTALA requires an "appropriate" medical screening exam (MSE), he says. "But the term 'appropriate' has never been defined by CMS [the Centers for Medicare & Medicaid Services] or any other group, so this is a wide-open invitation for CMS to determine after the fact that the diverted patient did have an emergency condition," Frank says. "They could also determine that the screening was not appropriate."
Frank says his understanding is that the facility was doing appropriate triage, but not necessarily an assessment. "I don't think they were only using physicians," he notes. "Under CMS guidelines, the hospital must use 'the full spectrum of its capabilities' in performing a medical screening exam." So, Frank explains, "If you have doctors in the ED, that is part of the 'full spectrum,' it becomes problematic to say you have done an appropriate MSE when it is done with nurses and paramedics and you don't use doctors."
The bottom line is that while such policies can follow the letter of the law, they still are risky, he says. "There's no way to be sure you will not run afoul of EMTALA with such a policy," Frank warns. "All it will take is one complaint, and EMTALA is complaint-driven."