Camera crews carry serious risks — stringent precautions are necessary

This is a very controversial topic, a real political hot potato’

[Editor’s note: In this first part of a two-part series, ED Management shows how important it is to exercise tight control over camera crews and what can go wrong if you don’t. Next month, we’ll explore how the Health Insurance Portability and Accountability Act (HIPAA) may complicate the issue and why a local news crew might be the riskiest of all.]

How’s this for a nightmare? You turn on the evening news one night and see your emergency department portrayed as a chaotic mess, with drunk patients urinating; screaming, ill-tempered staff ordering people around; and patients clearly identified on camera even though the news crew promised they wouldn’t be.

Then you go to work the next day and find half a dozen patients threatening to sue for invasion of privacy. Wasn’t this camera crew project supposed to be good public relations for your ED?

That nightmare can come true if you allow a camera crew in without extremely tight controls, say those who have been through the experience. Camera crews are becoming an increasingly common sight in EDs as documentary television shows flourish and long-held prohibitions on photography fall; but those who have hosted the media say the experience can be positive and beneficial only if you expend a lot of effort to do it right.

It used to be rare that an ED would allow journalists with a camera past the waiting area, if they were allowed that far. But some experienced ED managers now say you should consider allowing them to videotape every nook and cranny of your ED because it can help educate the public about what really goes on in your workplace and the demands placed on staff. The experience even can be helpful to the patients who are photographed, says Kathleen J. Clem, MD, FACEP, chief of emergency medicine at Duke University Medical Center in Durham, NC. To her surprise, some patients told her that sharing their traumatic experiences with a viewing audience was therapeutic and helped them focus beyond their immediate pain and grief.

Duke recently hosted a camera crew from The Discovery Channel, in Silver Spring, MD, which videotaped Clem and the rest of the ED for about six months. The footage aired as part of the series ER Stories and still is repeated occasionally.

Though Clem says the experience was positive overall, she says ED managers would be justified in expressing some skepticism at the initial request to allow a camera crew in. And the request is likely to come sooner or later, Clem says.

"This is a very controversial topic, a real political hot potato," she says. "It raises a lot of questions about confidentiality and patient rights; but I think under the right circumstances, with the right preparation and the right standing rules, it can be a positive thing for the public and for the patients."

The Joint Commission on Accreditation of Healthcare Organizations first addressed the issue in July 2000 and then issued two standards clarifications that say filming or videotaping is acceptable under some circumstances. Patient consent must be obtained, and the hospital must retain control over what footage is aired, according to the Joint Commission. The American College of Emergency Physicians (ACEP) recently issued similar guidelines.

Strict limits are a must

Rules and limitations are the key. That message is stressed by Clem and others who have allowed cameras in their EDs, such as Jim Scheulen, PA, administrator for the emergency medicine department at Johns Hopkins Hospital in Baltimore, which allowed unprecedented access to camera crews for ABC Television in 2000. The footage from the Hopkins ED and other areas of the hospital was used to create the series Hopkins 24/7, which aired that year.

Scheulen had some misgivings about the idea when the public affairs office first suggested allowing a camera crew in his ED, but extensive preparations resulted in "one of the smoothest, positive experiences you could imagine. Not at all what we expected."

A top concern is protecting the patient’s right to consent for such videotaping. You must devise a system that ensures that the patients’ rights trump any desire by the camera crew for good footage, Clem says. At Duke, the rule was that the patient had to give permission for the film crew to come in to the treatment area and videotape, with the only exception being for ambulances bringing in patients. In those cases, the crews were allowed to videotape and then ask for consent later.

"The controversy arises from the fact that you’re filming before getting permission, even though the family has to give permission before it’s aired," Clem says. "But in my six months of having a camera crew follow me around all the time, that was not an issue for any patient. It’s a theoretical concern, but I’ve not actually seen that it’s a real concern for patients. In fact, the people who were unhappy were the ones we didn’t film. We got complaints saying they wanted to be on TV, too."

Clem and Scheulen say they were happy with what aired on television after the taping was complete, but they note that their written agreement with the camera crews allowed them to veto any scenes, so there were no surprises. The Hopkins 24/7 show included a segment in which ED staff were shown after their shift ended, laughing at how a patient had urinated on a nurse’s leg. Some critics claimed that the scene portrayed Hopkins in a bad light, but Scheulen says the scene showed the reality of working in an ED and was not disrespectful to the patient.

At Duke, Clem says the camera crews were allowed to film only after they agreed in writing to turn over all final control to the hospital. Any staff member had the power to veto the camera crew in any situation.

"If I, or a nurse, or anybody on staff said, This isn’t appropriate to show the whole family crying because grandpa died,’ they had to stop. No argument," Clem says. "Anybody could walk over and say, Turn the camera off.’ The crew never argued about it because that was one of the ground rules."

Duke also had final veto rights over anything shown. The producers showed the raw footage to hospital representatives before it was shown to The Discovery Channel, and then they showed Duke the final edited version before it was aired. The hospital didn’t demand any changes because the crew already had edited out anything that might be objectionable.

Clem acknowledges that there are many who criticize the intrusion of cameras in the ED, but she says the experience was worthwhile because it helps educate the public about "real emergency medicine, not just what’s portrayed on ER. They get to see our struggles every day." The taping actually provided a direct benefit one day when a patient complained about poor treatment in the ED, claiming that staff had treated him roughly and used obscenities. The patient already had threatened a lawsuit when the hospital officials asked the camera crew to show the videotape of the encounter.

"It turned out that everyone was nice and gentle, and no one used any foul language at all," Clem says. "We let the patient see the tape, and that was the end of that."

Johns Hopkins had "two or three cases where things got a little testy" between patients and the camera crews, says Gary Stephenson, a spokesman in the public affairs office at Johns Hopkins who helped coordinate ABC’s videotaping of Hopkins 24/7. Families sometimes complained that the camera was intruding on their grief, but the crews always stopped videotaping when anyone complained.

Clem underscores that you must retain control at all times. Though she is generally supportive of efforts to videotape in EDs, she cautions, "It won’t be OK unless you can set it up the way we did. Without those controls, there’s no way I’d let a film crew in my emergency department."

Sources

For more information, contact:

Kathleen J. Clem, MD, FACEP, Chief of Emergency Medicine, Duke University Medical Center, Durham, NC 27710. Telephone: (919) 684-5537. E-mail: clem0002@mc.duke.edu.

Jim Scheulen, PA, Administrator, Johns Hopkins Department of Emergency Medicine, 600 N. Wolfe St., Marburg B-186, Baltimore, MD 21287-2080. Telephone: (410) 955-8708.

The Joint Commission on Accreditation of Healthcare Organization’s standards clarification is available at: www.jcaho.org. Select the search option and enter "videotape."

Guidelines from the American College of Emergency Physicians (ACEP) can be found at http://www.acep.org/1,32402,0.html.

For a comprehensive review of the issue, see: Geiderman JM, Larkin GL. Commercial filming of patient care activities in hospitals. JAMA 2002; 288:373-379.