Ravenswood: A dilemma for all risk managers

Catch-22: Liability vs. humanity

A Chicago hospital is under fire for an incident in which emergency department (ED) staff refused to go outside and treat a dying patient, but the controversy apparently was generated by a risk management policy that is common to most hospitals. The hospital's staff followed the policy as they were instructed, but the resulting criticism may lead risk managers across the country to reconsider their own policies on the topic.

The incident occurred at Ravenswood Hospital Medical Center on May 16, when 15-year-old Christopher Sercye was shot less than a block from the hospital. His friends and police officers responding to the incident went to the hospital and pleaded with ED staff to come the short distance to where the boy lay bleeding, but they refused. Police eventually took the boy inside the hospital, but he died after treatment.

The hospital staff came under fire for what appeared to be a callous refusal to step outside when emergency treatment was needed, but staff were only complying with a hospital policy that prohibited them from leaving the building to treat patients. Risk management experts tell Healthcare Risk Management that such a policy, or some variation that limits staff to the hospital campus, is common among health care facilities.

Such policies usually are intended to protect the staff from dangerous situations on the street, as well as to ensure the ED is staffed properly at all times. Nevertheless, Ravenswood officials issued a statement that the policy had been revoked two days after the incident.

The risk manager at Ravenswood, Janet Iron, declined to comment on the incident except to say she was busy meeting with attorneys because of "preliminary things about litigation" and that hospital counsel had put everyone in the "no talking zone," which is common when litigation is likely. Neither she nor a hospital spokesperson would comment on whether the hospital is being sued by the family of the gunshot victim.

In comments to the media during the controversy, hospital officials stressed that the ED staff did not just ignore the pleas to come outside and help the victim. Police first told the staff there was an injured person nearby and that 911 had been called. The ED staff called 911 to confirm that paramedics were en route, and according to the hospital, the fire department arrived to help the boy within minutes of the hospital's call to 911.

Some of the facts regarding the timing of the calls to 911, when the fire department arrived, and the actions of ED staff are in dispute. "Our employees followed hospital policy," says John E. Blair, president and chief executive officer of the hospital. "As time passed and it became apparent that paramedic response was delayed, I personally wish that we had gone out to see if we could have helped Christopher directly."

JCAHO, state are investigating incident

The incident received extensive publicity, which has prompted investigations by the state health department's Division of Health Care Facilities and Programs, the Joint Commission on the Accreditation of Healthcare Organiza tions (JCAHO), and the U.S. Department of Health and Human Services. The state health department issued a statement saying it was investigating the facility for a possible violation of laws against "patient dumping." The JCAHO sent an investigator to the facility recently to determine what happened, says spokeswoman Janet McIntyre.

"The issue is that there was a death that happened at an accredited hospital, and the question has been raised as to whether there was some action the hospital could have taken to avoid the death," she says. "From the Joint Commission's perspective, there is no standard requiring medical personnel to go off campus to deliver care. We've found that most hospitals do have their own policies that address their own particular need in whether personnel can go off campus."

McIntyre says the JCAHO is "concerned that maybe this could happen at other health care organizations." She notes there were conflicting reports in the press about what happened, so the primary goal of the JCAHO visit was to get the facts from the hospital.

Depending on the final report from the hospital visit, the JCAHO may decide to take other action, but McIntyre says there are no plans at this point to declare the incident a sentinel event or conduct a further investigation.

The U.S. Department of Health and Human Services threatened to cancel the hospital's Medicare participation within a month unless the hospital could prove it had changed the policy that led to the incident. President Clinton issued a statement at the same time pledging to pursue similar action against any other hospital that failed to provide care in a medical emergency. A hospital spokesperson confirmed that the facility "has received a preliminary determination letter from the Health Care Finance Administration [HCFA] which gives us until June 21, 1998, to demonstrate to HCFA that we are in compliance with its requirements to maintain Medicare funding."

Policy didn't work 'in the spirit' intended

To preserve participation in Medicare, Ravenswood officials planned to provide proof that the policy had been changed soon after the incident. Two days after the incident, Blair issued a statement explaining that, "after considerable thought and a preliminary review of this incident, I have revoked the policy which prevented our emergency room personnel from going outside to treat Christopher Sercye.

"I have instructed my staff to provide treatment to anyone who needs it in the immediate vicinity of the hospital when there are no paramedic or emergency medical technicians available, consistent with due regard for the safety of all, including this hospital's personnel.

"Above all, I want to make sure that if a tragedy like this ever occurs again, we have a different result. Our staff followed hospital policy in handling Saturday's unfortunate shooting, and the events surrounding the shooting were volatile and uncertain. But I believe the policy did not work Saturday in the spirit in which it was written more than a decade ago, and therefore, I am taking immediate action to change it."

Chicago aldermen also responded with proposals that would force hospital staff to treat patients in similar situations. One proposal would strip hospitals' general business licenses and impose fines of up to $1,000 on hospitals whose staff refuse to treat patients within 150 feet of the facility. Hospital administrators who interfere in treatment, including risk managers who implement a policy prohibiting off-campus treatment, would face up to 90 days in jail.

Another proposed ordinance would require treatment within 1,000 feet of the hospital, and another would deny tax-exempt status and free water to hospitals that refuse.