Ravenswood Update

ED policy requires good judgment, common sense

HCFA: Hospital retains Medicare accreditation

The Health Care Financing Administration (HCFA) in Baltimore has approved Ravenswood Hospital's revised emergency department (ED) policy, and has determined that the hospital will continue to receive Medicare funding. The decision comes on the heels of an incident at the Chicago facility in May involving a 15-year-old boy who was denied care outside the ED because of a hospital prohibition on hospital personnel bringing patients into the ED. (See the July issue of Hospital Peer Review for details regarding this incident.)

HCFA considered the applicability of patient-dumping laws and was poised to terminate Ravenswood's Medicare participation pending adequate corrective action. Substantial and adequate remedial steps were taken, and HCFA based its positive decision on a resurvey of the facility, a study of the new policy, and its approval of an inservice for hospital employees.

In a statement, John E. Blair, the hospital's president, said Ravenswood's revised trauma policy allows hospital staff greater flexibility in assessing the medical needs of people injured on or in close proximity to the hospital campus. "This plan gives our staff another channel through which they can proactively respond to people who need our care," Blair said. Under the policy, hospital employees are required to call a dedicated internal telephone number to report cases of individuals on or in close proximity to the hospital campus who need immediate medical assistance. The number provides instant access to an ED nurse and physician who will determine how best to treat the person consistent with federal law and revised policy. Dan Parker, vice president of public relations of Advocate Health Care, says employees were trained on the new policy via video and live presentations.

"It's bad press for the hospital any way you look at it," says Mark A. Kadzielski, JD, head of the health law firm Epstein, Becker, & Green in Los Angeles. Hospital Peer Review asked Kadzielski, "What if the boy were just beyond hospital property lines?" He replies, "Technically, the answer is, `No, COBRA and patient-dumping issues would not apply,' but then you get into questions of `How close is close enough?'"

Charlotte Yeh, MD, FACEP, chief of emergency medicine at New England Medical Center in Boston and a member of HCFA's task force on patient-dumping laws, says when the boy was dragged to a retaining wall at the border of the hospital's property and his friends entered the ED requesting assistance, "HCFA interpreted that as a request for care on hospital property. The fact that the hospital failed to provide care is what triggered the anti-dumping violation investigation."

Hospital Peer Review asked Yeh what a hospital's ED policy should state regarding an individual requesting aid from outside hospital property. "It's case-specific," she says. For example, to require going to the aid of someone across the street won't be feasible because the street may be a four-lane highway - or just an alley. You cannot mandate a specific policy one way or another because the facts and circumstances are so individualized.

"You can't make a blanket statement on whether personnel should or shouldn't respond. It depends on the situation," she says. "There should be no prohibition against care, but there also should be no mandate." Anytime there's a request for help, staff safety has to be considered. In addition, you can't abandon existing patients. Third, you can't ask your staff members to act beyond their capabilities. If personnel are not trained to stabilize patients on the street or in an office - if they are trained to work with the hospital equipment at hand - they can render first aid but not go further than that. Another issue has to do with such practicalities as elevator and hallway size. "A call to 911 may make more sense because they have special equipment," says Yeh.

Most experts say common sense and judgment calls come into play in this situation more prominently than HCFA and hospital policy issues. The American Hospital Association (AHA) in Chicago has stated that hospital trauma policies vary from institution to institution, but they "only go so far. . . . It ought to be much more a matter of common sense and human judgment that prevails."

The AHA advises taking the following steps to avoid a Ravenswood incident:

· Make sure you know what your ED policy says regarding sending staff outside, and even off hospital premises, to deliver care. Does it allow flexibility for good judgment?

· Educate and refresh your ED staff on the policy, and include other appropriate departments such as communications and security.

· Reconnect with community emergency response agencies to ensure coordination and understanding of each entity's responsibilities.

Why Ravenswood almost lost it

One requirement of Medicare participation is compliance with the federal Emergency Medical Treatment and Active Labor Act (EMTALA), enacted in 1986 to eliminate patient dumping. EMTALA is a part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), and states that any person presenting on hospital property and asking for help must be screened and stabilized within the facility's capabilities. Hospital property is defined as buildings, parking lots, and walkways on the hospital campus.

Depending upon the severity of a COBRA violation, the OIG can impose a 180-, 90-, or 23-day termination of Medicare participation, and with that goes Medicaid termination. Once a hospital is put on termination, Medicare fiscal intermediaries are notified, and they typically put a hold on reimbursement until the final disposition of the problem. To make things worse, managed care contracts are likely to be terminated because most are premised on Medicare participation. The OIG also can impose civil penalties up to $50,000, and COBRA can authorize private lawsuits against hospitals for violations. In short, a facility's funding is cut off at the knees.