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ED Not a Stroke Center? Patient May Sue for Failure to Transfer
With some hospitals being designated as demonstrating excellence in the care of stroke patients, does this mean a patient can successfully sue the ED if he or she is not treated at one of those facilities?
a.patient's lawsuit may involve the failure to transfer a patient to a stroke center where tissue plasminogen activator (tPA) or another therapy is available, notes John Burton, MD, chair of the Department of Emergency Medicine at Carilion Clinic in Roanoke, VA.
"That doesn't mean that it's standard of care, from a legal standpoint, that patients have to be treated at those hospitals," says Burton. "But it does mean that every ED should be asking the question, if they are a stroke center, 'What are the standards we should be held to?' And if you are not a stroke center, what are the ED's processes for getting patients to stroke centers in their area?"
Well Thought-out Plan
The ED and the hospital need to decide if they are going to engage in providing the thrombolytics and admit the stroke patient to their own facility, or transfer the patient to a receiving hospital, says Matthew Rice, MD, JD, FACEP, an EP with Northwest Emergency Physicians of TEAMHealth in Federal Way, WA. Regional programs are another option, he adds, with smaller hospitals consulting with a stroke center as to whether they should provide thrombolysis.
"From a risk perspective, that is somewhat protective of the smaller hospitals, because they have regional experts consulting as to what circumstances it should or should not be given," says Rice. "You are basically conferring some of the risk to consultants, for 'Should we give this or not?'"
Robert B. Takla, MD, FACEP, chief of the Emergency Center at St. John Hospital and Medical Center in Detroit, MI, reports that his facility goes beyond even the 4.5 hour extended treatment window for tPA in some cases, with the use of intra-arterial tPA.
"We keep pushing the envelope on this one. We might even be able to give therapy at any point in time," says Takla. Other possible options for stroke patients include specialized CT perfusion scans and endovascular procedures where intra-arterial tPA is provided at the site of the lesion.
"If there is a stroke center in your community, and you are not practicing at that center and you are caring for a stroke patient, then a process should be clear," says Burton. "Do you move that patient to the stroke center, or do you continue taking care of them in your hospital?"
Telemedicine May Reduce Risks
Smaller hospitals potentially can reduce their liability risks by providing telemedicine services, according to Hartmut Gross, MD, a professor of emergency medicine at Medical College of Georgia in Augusta. Gross is co-founder of REACH (Remote Evaluation of Acute isCHemic stroke), which provides telemedicine services to 16 hospitals, including giving tPA with consultation over the Internet.
"We make a recommendation. That is documented and becomes part of the patient's medical record, regardless if they are transferred or not," says Gross. "If I am doing the stroke consult and I am the person making the recommendation, my name is now on that chart. If there is a bad outcome, I am going to court, and that's only fair." The REACH consultants have done more than 1,200 consultations with more than 270 tPA administrations. Without telemedicine capability, he says, "those numbers would have been basically zero."
Gross notes that Georgia recently passed legislation mandating that hospitals either subscribe to a stroke network or have patients diverted by emergency medical services to the nearest stroke-capable hospital.
"The idea is that any patient could be within 30 minutes of stroke care, regardless of where they live," says Gross.
Regardless, notes Gross, it still takes time to transfer the stroke patient. "You may be lucky and have an ambulance to transfer the patient to a not-too-distant place and the stars all align properly," says Gross, but in other cases, transport times might be long.
"Even waiting on a helicopter, you are going to lose time," says Gross. "Even if you give the tPA right there on the helideck, the patient is usually out of the window and you are too late. If you can give tPA rurally, then the time monkey is off your back."
Burton notes that the standard of care for trauma patients has evolved in recent years. "We've made a very clear decision in the last 30 years in emergency medicine, that if you have a high-acuity trauma patient, that patient needs to go to a Level 1 trauma center," says Burton. "That means if you practice at a Level 1 trauma center, the way you take care of patients has certain processes. And if you don't, you need to standardize the processes for getting patients to Level 1 trauma centers."
Likewise, says Burton, the EP needs to have a well thought-out plan for the care of stroke patients in their specific ED.
a.stroke patient doesn't necessarily have to be transferred to a stroke center, says Burton. "But you do need to have a set of processes for how to treat those patients, and when you might move them to a stroke center," he says. "That is something that every ED has to consider."
For more information, contact:
John Burton, MD, Chair, Department of Emergency Medicine, Carilion Clinic, Roanoke, VA. Phone: (540) 266-6331. E-mail: JHBurton@carilionclinic.org.
Hartmut Gross, MD, Department of Emergency Medicine, Medical College of Georgia, Augusta. Phone: (706) 721-7144. E-mail: firstname.lastname@example.org.