National emergency declaration creates H1N1 options for EDs
National emergency declaration creates H1N1 options for EDs
Relaxation of EMTALA, HIPAA guidelines will help speed care
On Oct. 24, 2009, President Barack Obama signed a national emergency declaration to help the nation's health care providers to better respond to the H1N1 pandemic. While the White House emphasized that this step was proactive, the numbers of cases have been rising steadily at press time, with a particularly strong impact on pediatric patients.
The declaration enables hospitals and other bodies such as county health departments to apply for specific waivers that would ease the restrictions of national laws such as EMTALA (the Emergency Medical Treatment and Labor Act) and HIPAA (the Health Insurance Portability and Accountability Act). In the president's proclamation, several examples of possible waivers were outlined, including:
- Hospitals request to set up an alternative screening location for patients away from the hospital's main campus (requiring waiver of EMTALA).
- Hospitals request to facilitate transfer of patients between EDs and inpatient wards between hospitals (requiring waiver of EMTALA and HIPAA regulations).
The entire proclamation can be found at www.flu.gov/professional/federal/h1n1emergency10242009.html.
The move was applauded by emergency medicine and disaster preparation experts. "The lifting of restrictions can be helpful in communities that have a high surge of flu patients," says Pat Crocker, MD, FACEP, chief of emergency medicine at Dell Children's Medical Center in Austin, TX.
The declaration opens up new options for ED managers, says James Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians, an emergency physician partnership group in Canton, OH, and a member of the emerging diseases committee of the International Association of Fire Chiefs in Fairfax, VA. "ED leaders can begin to look at things like alternate care sites, relaxation of rules of EMTALA under very clear circumstances that allow EDs to see higher volumes of patients, he says. "They can begin a planning process now and start to think creatively about what to do if this worsens and there is growing pressure on the hospital to deliver care."
Also supportive of the declaration is Kristi L. Koenig, MD, FACEP, professor of emergency medicine, director of public health preparedness, co-director of EMS and disaster medical sciences fellowship at the University of California at Irvine School of Medicine, and a member of the American College of Emergency Medicine's (ACEP) H1N1 expert panel. "This will be very helpful for doctors and nurses who work in EDs because it will relieve some of the administrative burden," she says.
In addition, notes Carl Schultz, MD, FACEP, professor of emergency medicine at the UC Irvine School of Medicine and chair of ACEP's disaster preparedness and response committee, "It provides some options that normally don't exist in terms of transfers and protecting privacy."
Understand new reality
One of the most important things ED managers can do is to make sure that they, their staffs, and their hospital leadership understand exactly what this declaration means, Koenig says.
"This is relatively new information," she explains. "It's good that it came out now, so people can have time to understand it, meet with legal counsel, and work on how they would operationalize their response if things came to that."
Thus, for example, when it comes to seeking alternative care sites, "even if they were on hospital grounds, if they were more than a certain distance from the main building, it could be problematic in terms of seeing patients," says Koenig. "So it's common sense for people to look at drive-thru clinics and things like that."
When it comes to EMTALA, it's important for staff to understand what the law means without a waiver, as well as what a waiver would mean, she says. "Any patient who presents to a hospital seeking care must be provided a medical screening exam [MSE] and stabilized up to the capability of that facility," Koenig says. "If a waiver is enacted, you could, for example, refer patients to alternate care sites without doing the same documentation and type of assessment."
There might, for example, be a clinic across the street, she says. "Under normal conditions, you'd do a full MSE and stabilize that patient," Koenig says. "With a waiver you could possibly just give them a quick look and say 'You're stable enough to go across the street and get your care.'"
Schultz agrees. "Instead of having the patients sit in the ED waiting for a bed, you do a quick screening, and if the vital signs look good, you can send them to another facility," he says.
Augustine says, "The waiver process can assist in dispositioning patients from the ED as well. A flu patient on a ventilator might need to be transferred to another hospital which has available beds, which on a regular day in your hospital day would be well within the capability to manage."
Potential HIPAA waivers also must be understood, says Koenig. "It's important for administration to work with the legal counsel and make sure they understand what the waivers would do for them, and educate people on the front lines if they go to implementation," she notes.
So, for example says Schultz, "It may not be possible to guarantee that much [privacy] protection. You may use forms that are not typical to send the patient to another screening place. Normally that information would only be sent to your medical records department."
In cases where a HIPAA waiver is sought, note the experts, EDs probably would use different screening and registration forms. You might conduct a quick medical exam on patients, decide they have the flu, and start to move them to a department of health clinic. You would fill out a form so that the providers at the health clinic will see that you have screened the patient. This type of information — which of course would include information identifying the patient — would never leave your hospital or your medical records system under normal circumstances.
Inservices would be a good way of offering staff education and training, Koenig suggests. This training is critically important because government regulations and recommendations have been changing rapidly in areas such as which patients should receive antiviral medications, she emphasizes.
"They have to be aware of how things would work differently and be kept up to date on how to protect themselves and their patients," Koenig says. The best sources of up-to-date information would be the web site for the Centers for Disease Control and Prevention (CDC). (Editor's note: For the CDC conference calls for education and training, see www.cdc.gov/h1n1flu/clinicians/#resources. For specific portions of the web page for clinical information, go to www.cdc.gov/h1n1flu/clinicians, www.cdc.gov/H1N1flu/antivirals, and cdc.gov/h1n1flu/update.htm.) Another source would be local health departments, she says.
She has been involved with initiatives such as the ACEP H1N1 Expert Panel (acep.org/practres.aspx?id=45347). "One document we've developed called the National Strategic Plan for ED Management of Outbreaks of Novel H1N1 Influenza has been particularly popular," she says. (It is available free of charge at acep.org/WorkArea/DownloadAsset.aspx?id=45781.)
Another good source is The New England Journal of Medicine/Journal Watch — H1N1 Influenza Center (h1n1.nejm.org), she says. "Of course, the World Health Organization also has excellent updates, but they are not uniformly consistent with U.S. policies and procedures," she notes.
When should you ask for a waiver? As a result of President Barack Obama's National Emergency declaration of Oct. 24, 2009, hospitals may request waivers from certain requirements of the Emergency Medical Treatment and Labor Act (EMTALA) and the Health Insurance Portability and Accountability Act (HIPAA) if the H1N1 outbreak threatens to overburden them, but exactly what is the right time to petition for a waiver? Although it is the facility that makes the formal request, the initiative often comes from the ED, notes Carl Schultz, MD, FACEP, professor of emergency medicine at the University of California at Irvine School of Medicine and chair of the American College of Emergency Physicians' disaster preparedness and response committee. "You would try to anticipate [the need for a waiver] based on acuity and volume," Schultz says. "If acuity is low, for example, then you could tolerate higher volume, but at some point you might see the need to implement surge plans." You can track items such as the number of cases seen and wait times to learn at what point the things you do in a normal situation won't work, he says. Describing the situation at his ED in early fall, Pat Crocker, MD, FACEP, chief of emergency medicine at Dell Children's Medical Center in Austin, TX, says, "At our peak volume, we were seeing over 400 patients a day." While waivers were not available then, Crocker used similar benchmarks to determine the need for external tents. "Our typical census is 180 patients a day," he says. "We struggled all summer with planning to try and pick some daily census that would be the tipping point." When it got to the point where lengthy waits caused more patients than normal to leave before being seen, the tent option was implemented. "The breaking point was somewhere around 300 a day," says Crocker. That represents a volume about 70% over normal, which is a value that many ED leaders would consider high enough to implement disaster operations. Schultz says, "When you reach such a point, the ED manager should go to the incident manager and tell them, so they can apply for a waiver." |
Tents expand capacity of peds hospital's ED When the rate of patients leaving before treatment at Dell Children's Medical Center in Austin, TX, suddenly shot up to 12% in mid-September as a result of the H1N1 pandemic, Pat Crocker, MD, FACEP, chief of emergency medicine, knew it was time for action. Crocker had three tents put up outside the ED to handle the surge. The tents previously had been purchased in the aftermath of 9/11 and used during two hurricanes. During peak hours, he positioned a triage nurse outside the ED entrance. "If a patient had a cough, congestion, fever, sore throat, was over [age] 2 and had been ill for less than 48 hours, they got pulled out of the mix and went to the tents," says Crocker. The tents are 34 x 18 and fully climate-controlled. The first of the tents had a full triage station and chairs for waiting patients. The other two tents had 12 care spaces with collapsible "disaster-type" beds with foam pads. "From the time the patient saw the triage nurse to the time they were out of the tent, it took only 20-30 minutes," Crocker reports. "We used pre-printed charts even though we had connectivity to the hospital system, because they were so much faster." The tents, which cost $40,000 each, were equipped with flu and strep testing supplies and medications. They were provided by Western Shelter Systems of Eugene, OR. The day after the tents opened, the rate of patients leaving before treatment had been slashed to less than 1%. "They were highly effective," Crocker says. The tents were closed when volume dropped below 250 a day. The peak had been more than 400 daily. If a surge returns, they easily can be erected again, Crocker says. "It takes about two hours to set them up," he says. |
AHRQ tool helps you find alternative care sites The Agency for Healthcare Research and Quality (AHRQ) has released two free interactive computer tools to help emergency planners and responders select and run alternate care facilities during disaster situations. The two tools allow users to input information on their specific medical care needs and receive feedback on which facilities can become alternate care sites or which patients can appropriately be moved to those sites. The Disaster Alternate Care Facilities Selection Tool is an interactive worksheet that assists users in selecting sites and identifying what they need to prepare these sites for use. It evaluates the characteristics of several potential facilities and calculates the results into weighted scores, which planners can use to select appropriate sites for care and plan for operations during a disaster. The Disaster Alternate Care Facility Patient Selection Tool is a decision support tool that matches a hospitalized patient's clinical needs with the capabilities of an alternate care facility. The tools can be downloaded at www.ahrq.gov/prep/acfselection. |
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