ED controversy triggers policy changes

Chicago hospital says rules prevented boy's rescue

A 15-year-old boy lay bleeding from a gunshot wound just steps away from Ravenswood Hospital in Chicago on May 16 . According to news reports, emergency department (ED) personnel refused to help him because of a hospital rule requiring that ambulances bring in patients. The boy died, and that tragic incident has triggered hospitals throughout the country - probably including yours - to do some soul-searching: "If this had happened in our hospital, what would we have done?"

Richard Wade, senior vice president for communications at the American Hospital Association in Washington, said in a statement that common sense should have prevailed over policy and that many facilities are now reviewing their trauma care procedures as a result of this incident. The association has released a new set of guidelines recommending that hospitals change any policies that would prevent staff from taking appropriate actions in a medical emergency. Some have already made changes.

"It appalls me that someone would do that. I would rather be sued for going out and helping someone than for ignoring them," says Edward Brandenburg, vice president of operations and risk manager at Community Memorial Healthcenter in South Hill, VA, a 284-bed sole community provider. "So as long as I have any say, we will go outside the building and help." That facility's liability insurance covers medical incidents on or off the property. "Even if one of our employees stopped at an accident scene and rendered help, our liability insurance would cover that," he says. Community Memorial has no written policy on such events, but is currently formulating a new policy as a result of the Ravenswood incident. "Every facility should have some kind of written guideline," Brandenburg says.

The event happened in an accredited hospital, and a surveyor from the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, visited the hospital on May 20. The Joint Commission is considering viewing this as a sentinel event - an unexpected death. Although the boy was not a patient of the hospital, Ravenswood could be expected to conduct a root-cause analysis. Some experts, however, question the Joint Commission's motives in investigating an incident like this. Is the agency more interested in getting media attention than in creating a database of events?

Hospital Peer Review asked Janet McIntyre, a Joint Commission spokeswoman, why a person outside the hospital, not an admitted patient, falls within the Joint Commission's purview. How does this incident meet the definitions of the sentinel event policy? What makes it a reportable event?

"The question is raised whether there's some action that the hospital could have taken to avoid the boy's death," says McIntyre. "The Joint Commission is requiring the hospital to look at how and why, and what they might do to avoid such an event in the future."

She said the situation is complicated by the fact that the Joint Commission has no standards requiring personnel to go off-campus to administer care. "Most organizations put an emphasis on treating patients within the facility. This is an issue we can all learn from," says McIntyre. "There are broader, societywide issues here. What is the obligation of the public to come to the aid of someone in need? Do people with special skills have special obligations?"

Policy: 'You don't leave patients'

Many EDs have guidelines or policies that keep personnel inside so patients are not neglected and so employees are not exposed to hazards. John Blair, president of Ravenswood, an affiliate of Advocate Health Care in Chicago, told media the policy was put in place at his facility because "the first priority of emergency room staff is to care for the patients already in the department . . . you don't leave patients who need your attention."

The day after the incident, Blair ordered the policy modified, saying staff have been instructed to provide aid to anyone who needs it in the immediate vicinity of the hospital until treatment is turned over to paramedics or emergency medical technicians responding to a 911 call. "Above all," Blair stated, "I want to make sure that if a tragedy like this ever occurs again, we have a different result." In addition, a multidisciplinary task force has been formed to address practices or policies in place at all Advocate facilities.

If similar circumstances were to occur today, Ravenswood personnel would not be constrained by policy in deciding to go outside the ED to provide treatment, says Dan Parker, vice president of public relations of Advocate Health Care. "Our take on this from the beginning, even with the former policy, was that this was a question of judgment. At the moment the decision may have seemed appropriate, because the staff may not have understood the full scope of what was happening." In retrospect, Blair says he wishes someone had felt it appropriate to go outside. "But that's with the benefit of hindsight," says Parker. There is a draft policy yet to be reviewed by appropriate departments at Ravenswood, including medical and administrative staff.

(Editor's note: Does your trauma policy bear reviewing? Where do COBRA and EMTALA fit into all of this? The next issue of Hospital Peer Review will contain information on what your facility should be looking at if it develops a new ED policy in the wake of the Ravenswood incident.)