Inconsistently Available Specialty Services in ED?
Inconsistently Available Specialty Services in ED?
Clinical disasters may result
If an ED claims to have certain services available, that creates a duty to provide them, according to Douglas S. Diekema, MD, MPH, an attending physician in the ED at Seattle Children’s Hospital and director of education for the Treuman Katz Center for Pediatric Bioethics at Seattle (WA) Children’s Research Institute.
If an ED claims to offer a service, and someone comes seeking that service or is brought there by an ambulance in the belief that the service is available, and the ED does not provide the service and the patient comes to any harm, “there would be significant risk of legal liability,” says Diekema. “At a minimum, they would be at risk of a tort claim, should the patient choose to pursue one.”
The ED might also be at risk of violating state or federal laws, including the Emergency Treatment and Active Labor Act (EMTALA), says Diekema.
A successful lawsuit requires finding that the hospital had a duty, failed to carry out that duty, and the patient came to harm as a result, notes Diekema. “One could argue that a hospital that has the capacity to offer a service, leads the community to believe that they offer the service, and then fails to offer the service at certain times, has failed to carry out its duty to the patient,” he says.
Diekema says that these situations may put the hospital at more risk than the provider, adding that if the provider is on-call and expected to be on duty, the provider would be at risk.
“However, it would be unreasonable to hold a single provider to the duty to always be available,” he says. “Rather, the hospital has the duty to assure that they have sufficient coverage to offer the service during those hours that are necessary to safeguard the welfare of their patients.”
Services Unavailable
Hospitals may claim their emergency departments have expertise in specialty areas, only to fall far short of their promises, warns Andrew Garlisi, MD, MPH, MBA, VAQSF, medical director for Geauga County Emergency Medical Services (EMS) in Chardon, OH, allowing a plaintiff’s attorney to successfully argue that these services weren’t available when the patient presented to the ED.
Garlisi gives the example of a community hospital that claims to be a specialty center for treatment of sepsis. Although the hospital has an intensive care unit (ICU), and an intensivist is available onsite during certain daytime hours most days, the intensivist is not available after 5 p.m. or on weekends or holidays.
If a patient with severe sepsis is admitted from the ED to the ICU on Saturday evening, he or she may experience a steady decline in status through the night while a non-hospitalist staff internist awaits consultations from the infectious disease specialist and intensivist.
“The patient’s pulmonary status may deteriorate until a ‘rapid response’ is finally called, at which point, the on-site anesthesiologist intubates the patient and provides initial ventilator orders,” says Garlisi.
By the time the patient is actually seen by the admitting internist the following morning, he or she might not survive due to further clinical deterioration, with elevated troponin levels, worsening metabolic acidosis, and increased lethargy.
“The patient never had the benefit of intensivist, infectious disease, pulmonary, or cardiology consultations — even though timely consultations from such specialists would be expected from a hospital claiming to have expertise in the management of sepsis,” says Garlisi.
In another example, a community hospital might look to increase its ED volume by advertising itself as a level III trauma center, marketing itself to local EMS providers, and hiring a trauma coordinator.
In addition, Garlisi says, the hospital creates a policy and procedures guideline for trauma management, which clearly states that the on-call trauma surgeon will respond in person to the ED to the Trauma Alert page, which is defined by mechanism of injury and presenting signs and symptoms.
If a trauma patient arrives at the ED with signs of significant abdominal trauma, the EP may anticipate arrival of the trauma surgeon instead of transferring the patient to the level I trauma center, and begin a diagnostic evaluation including CT scans of the head, neck, chest, abdomen, and pelvis.
If there are significant delays in receiving CT interpretations due to the high volume of activity via teleradiology, and the trauma surgeon never presents to the ED because the patient’s vital signs were initially normal, the patient’s condition may suddenly deteriorate before he or she is finally transferred to the level I trauma center.
The delay in definitive care could possibly cost the patient his life, says Garlisi. “Bending to the pressure to maintain financial viability in a highly competitive health care market, some community hospitals overextend themselves,” he says. “They advertise services which they cannot consistently provide with high quality.”
To attract patients, EDs are marketing themselves as chest pain centers, stroke centers, trauma centers, geriatric centers, sepsis centers, and pediatric centers, explains Garlisi.
“If the facility has the capability and capacity to perform these services consistently — on weekends, holidays, and after 5 p.m. — no problem,” he says. “If the hospital can only perform any or all these services marginally and inconsistently, then someone will suffer and a price will be paid.”
Sources
For more information, contact:
- Douglas S. Diekema, MD, MPH, Treuman Katz Center for Pediatric Bioethics, Seattle (WA) Children’s Research Institute. Phone: (206) 987-4346. Fax: (206)-884-1091. E-mail: [email protected].
- Andrew Garlisi, MD, MPH, MBA, VAQSF, University Hospitals Geauga Medical Center, Chardon, OH. Phone: (330) 656-9304. Fax: (330) 656-5901. E-mail: [email protected].
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