New Jersey EDs closed because of on-call consultant response times

Although your ED may be in compliance with federal requirements, state regulations may be more stringent. Two EDs in Millville and Bridgeton, New Jersey, both part of the South Jersey Hospital System, were recently shut down after an investigation conducted by the Health Care Financing Administration (HCFA) triggered by on-call consultant issues. "HCFA follows state law as a term of your Medicare participation, so if you don't meet state law, you don't meet federal law," emphasizes Steven A. Frew, a Rockford, IL-based health care attorney and consultant.

Problems started after an internal disciplinary action against consultants to the ED was voted on by the hospital medical executive committee, and a report was filed with the state board of medical examiners. The state department of health, operating as the local HCFA representative, started an investigation and identified problems with consultant response times.

New Jersey state requirements for on-call consultants specify that consultants must respond to the ED within 30 minutes. "Because they put in parameters that consultants must respond in that time frame, then at 31 minutes you're in trouble," says Russell Harris, MD, FACEP, chair of the ED at Our Lady of Lourdes Hospital in Camden, NJ, and president elect of the New Jersey chapter of ACEP. "It's been in the regulations for several years but no one really paid a lot of attention-until now."

Many hospitals are revising their guidelines for consultant response times in light of the state regulations, says Harris. "Before, if it took a consultant 45 minutes to respond because of a traffic jam at the end of the day, things would come out just fine anyway, but this made everyone start to take notice of that existing regulation," he explains.

As a result of the findings, the EDs were temporarily closed during a weekend in December, and reopened the following Monday. Although the EDs remained fully staffed, all walk-in patients were stabilized and then transferred to other facilities, and local ambulances were stationed at the hospital to bring patients to other facilities. "The EMS community mobilized all of its personnel and equipment to make sure patients were put at the least risk possible," notes Frew.

Despite those efforts, patient care was affected. "The EDs opened two hours after the death of a young man with a heart condition who many people thought would not have died had he not been transferred 35 miles to another hospital, which is exactly what the EMS community had feared might happen," says Frew. The patient had a heart attack just a few minutes from one of the EDs that was closed, developed a new problem while being transferred to another ED, and died of those complications, he explains.

When the HCFA investigators ascertained there was no immediate threat to patient safety, the EDs were reopened, but the unprecedented action had broad ramifications for the hospitals. "Anyone who has reviewed the situation knows that quality patient care has always been rendered, and there was never an issue of less than standard medical care being delivered," says Robert Dinwoodie, DO, FACOEP, chairman of both the EDs. "Had they investigated further before closing the EDs, they would have found that the issues had already been dealt with appropriately."

ED managers were alarmed by reports of the closings. "This is absolutely frightening-this whole issue is a lightning rod, " stresses Harris. "ED directors are watching this very closely, and we are all very alarmed and on edge."

At issue were the ED's internal quality assurance minutes, which identified problems with on-call consultant response times. "The investigators read the minutes, but didn't take into consideration the solutions that were implemented," maintains Harris.

The problem has broad implications for quality assurance in the ED, says Harris. "As part of any ED's internal QA, cases are reviewed and discussed at monthly meetings, and you come up with an action plan to make things better," he explains. "The purpose of quality assurance is really to source problems and make them better, which was exactly what was done at the EDs that were closed."

Investigators failed to consider the steps taken to resolve the ED's consultant issues internally, says Harris. "The ED had documented problems and had programs in place to make every single one of them better, but investigators picked out the specific cases that were problematic and ignored the resolution of those problems," he notes.

The investigation brought to light the possibility of internal minutes becoming public record. "We always lived with the sense that performance improvement and quality assurance minutes were not a matter of public record, but this process has taught us they clearly can be," says Harris.

The scenario will likely strike fear in the hearts of well-meaning ED managers who identify potential problem areas in writing, says Harris. "The disturbing thing is that if the ED had swept things under the carpet, this never would have happened," he adds. "The logical message from this is that it's a risky endeavor to document the problems you have."

As a result of the investigation, the ED's minutes were made available to the media. Each of the 11 cases targeted by investigators appeared in the local papers, with detailed descriptions except for patients' names. As a result, at least one medical malpractice lawsuit was initiated that would otherwise never have occurred, says Harris. "The newspapers reported the lawsuit before the doctors even knew about it," he notes.

The aftermath of the HCFA investigation created internal problems for the hospital. "Of course, the medical staff has started to blame the ED for what occurred, but it really wasn't their fault," says Harris.

Responding within 30 minutes can be difficult for medical staff members who are on call at multiple hospital locations, says Dinwoodie. "But, frequently when ED physicians initiate telephone contact with an attending physician, it's just to notify them and not to request urgent backup, so the 30-minute rule applies only in critical cases, which is a significant minority of overall ED volume," he notes.

The incident alerted ED managers to the broader implications of the federal regulations. "It shows to what extent the government agencies can go under the EMTALA umbrella," says Dinwoodie. "This was history in the making, in that never before has a community hospital's ED been closed for an EMTALA violation."

Having your ED closed is a public relations nightmare for any hospital. "When events like this are broadcast in the media, people naturally jump to the conclusion that substandard care is being delivered," says Dinwoodie.

Education is essential to avoid this unpleasant scenario, stresses Dinwoodie. "Institutions need to hold inservices with medical staff and make sure that hospital policies and medical staff bylaws are up to date and in accordance with EMTALA regulations. This absolutely could happen to any other hospital in the state," he notes.

The state department of health has invited the ED community to revise the existing state regulations, with the goal of avoiding unnecessary closings in the future. "That will take at least a year to be initiated, but at least the process has begun." says Harris.

A liaison between the emergency medical community and the department of health helped to promote dialogue. "To have this ability to interact and exchange information is a huge step, because now there is input from all concerned people,' says John Brennan, MD, FAAP, FACEP, chairman of the ED at Northwest Covenant Medical Center in Danville, NJ. "Having an open dialogue is the best way to avert problems before they occur."

One possibility is creating a task force to investigate problem areas before shutting an ED's doors. "That way, if the state feels there are significant QA issues, the task force would mobilize and investigate," says Brennan. "That is an instrument the state will hopefully use before closing an ED."