Court ruling underscores sanctity of triage systems

EMTALA requirement cited

Hospitals may safely upgrade the patient acuity classifications of their emergency department (ED) triage systems, but they cannot downgrade them, for fear of violating the requirements of the Emergency Medical Treatment and Labor Act (EMTALA). That’s the reaction of EMTALA specialist Stephen A. Frew, JD, to a recent decision by the U.S. Court of Appeals for the First Circuit, which ruled that deviation from the triage classifications of a hospital may state a cause of action for violation of the law’s screening and stabilization requirement.

The appeals court overturned a lower court order dismissing the case of Edgardo Jose Cruz-Queipo, et al v. Hospital Espanol Auxilio Mutuo de Puerto Rico. According to the court opinion, the plaintiff alleged that the patient presented at 4 p.m. with complaints of chest pain, arm pain, and wrist pain, which was a Level II complaint under the hospital’s triage classification system.

The patient was triaged by a physician as Level IV (lower priority) for back and muscle pain, and chest pain complaints were not documented in the record at any point. The patient received an exam by another physician at 5:30 p.m. and an electrocardiogram and cervispinal X-ray were performed. The patient later was discharged with a diagnosis of thoracic outlet syndrome.

The following day the patient returned to the hospital ED with severe chest pain radiating to his left arm and jaw. He was diagnosed with an acute myocardial infarction and remained in the cardiac care unit for a week and then was transferred for a coronary artery bypass graft. The patient allegedly sustained permanent damage that could have been prevented by timely diagnosis and treatment on the first visit. The hospital conceded that if the patient had complained of chest pain, a different treatment protocol would have been required.

Conflict of evidence

A conflict of evidence on the issue of whether the patient had complained of chest pain required reversal of the summary judgment for the hospital and return to the trial court for a jury trial, according to the court’s ruling.

Frew, a risk-management attorney and web site publisher — — notes that in its ruling, the court went on to say that “the plaintiffs assert that if we accept that Cruz complained of chest pains during his Aug. 31 visit, we must also conclude that the hospital had a duty to stabilize the heart condition that culminated in a heart attack on Sept. 1. We agree.

“Cruz’s placement in Category IV despite a complaint of chest pains thus marked a departure from the hospital’s standards, which set the parameters for an appropriate screening,” the court stated.

In a footnote to the ruling, the court pointed out that the hospital “claims the patient’s heart condition was attributable to his ‘inability to adequately care for his physical condition’ by controlling his cholesterol and blood pressure, rather than to any action or omission of the hospital.”

Describing that argument as a “nonstarter,” the court noted that hospitals generally do not cause the emergency conditions that they are called upon to stabilize under EMTALA. “That does not mean, however, that a hospital’s failure to stabilize a condition bears no causal relationship to the damages suffered by a patient as a result of a deterioration in his condition that could have been avoided by stabilization,” the court added.

The case must return for trial, Frew explains, and whether or not the patient complained of chest pain and was improperly triaged is still under contention. Even so, he emphasizes, the case supports the standard Centers for Medicare & Medicaid Services (CMS) practice of citing hospitals for violation of their own policies and procedures, in particular for failing to note triage categories and selectively downgrading patients to lower classifications than specified in the policies.

“The initial reaction of many facilities,” he adds, “may be to suggest that they will remove classifications or make them entirely subjective. CMS, however, has repeatedly cited [hospitals] for lack of clear triage classification standards and practice.

“It is particularly salient,” Frew continues, “that the deviation from the triage system was not the result of a nursing judgment, but occurred based on a physician judgment.

“It is not uncommon to encounter the assumption in hospitals that the physician can override the triage system,” he adds.