Special Report
EMTALA Compliance Could Have Stopped Failure Cascade
by Stephen A. Frew, JD, Vice President and Risk Consultant, Johnson Insurance Services
On January 6, 2006, well-known Washington, DC, journalist David Rosenbaum had wine and dinner with his wife, then picked up his music player and headphones and went out for a walk. Those decisions, coupled with massive problems with the District of Columbia EMS and hospital system, allegedly caused Mr. Rosenbaum's death and sparked DC and EMTALA investigations that put police, firefighters, and EMS and hospital ED personnel in an extremely 'bad light' and facing major legal actions. The frightening truth, however, is that this debacle could have occurred in any hospital in the United States that is not fully compliant with EMTALA. Similar situations could easily happen in your hospital.
Unlike most cases that are only seen by a few involved in the actual litigation or in the resulting EMTALA citation, the Rosenbaum case caused a political out-cry sufficient to bring the Office of Inspector General (OIG) for Washington, DC, into the matter to investigate the performance of all of the city departments and personnel involved in the case. Even more unusual, the OIG released the scathing report while the possibility of litigation still looms over all involved.
Failure Cascade
The OIG report describes extensive failures in the entire police, fire, EMS, and hospital personnel response to the event, with only the district's 9-1-1 office and medical examiner's office receiving passing grades.1 (Editor's Note: A full copy of the 42-page report of the Inspector General in the Rosenbaum case is available at www.medlaw.com/dcoig.pdf.)
This is a classic example of how catastrophic outcomes are generally linked to a failure cascade — a total failure at every critical point in the process. This cascade or 'snow-balling' effect of errors typically can be stopped by a single person exercising normal judgment, but oftentimes no one does.
Timeline of Events
The OIG report establishes a sequence and description from which it is possible to reconstruct a timeline of the events in the Rosenbaum case and illustrate the cascading errors that allegedly contributed to significant delays in Mr. Rosenbaum's care.
January 6, 2006
21:00 — David Rosenbaum left his home for a walk.
21:10 — A neighbor in the area goes to his car and finds a man unconscious on the sidewalk. The neighbor and other witnesses suspect a stroke because of poor motor control on one side of the body, inability to sit up, and inability to respond to questions. The victim is described as looking like he "belonged" in the area.
21:27 — 9-1-1 receives notification of a "man down"
21:28 — 9-1-1 notifies Fire Dispatch
21:30 — Fire dispatch dispatches Engine 20 and BLS Ambulance 18. Engine 20 is located approximately a half mile from the scene. Ambulance 18 is finishing a call at a hospital located approximately 5.6 miles from the scene.
21:31 — Police dispatch MPD unit 2022; Ambulance 18 acknowledges the call. Ambulance 18's driver protests having to take the call, then departs for the scene going the wrong way.
21:35 — Engine 20 arrives at the scene. The officer in charge of Engine 20 is an "acting" officer with no EMS training. The crew also has two EMT's and one EMT-advanced.
The Engine crew found the patient on his back, moving, and moaning. Some described the moans as "growls." Patient had no wallet or identification. The patient's music device was not found, but the headphones were lying nearby. The patient was unable to sit up; firefighters sat the patient up against their knees to examine him. He kept slumping to one side. Witnesses reported that the firefighters tended to a wound on the back of the victim's head, which was later corroborated by police statements, but firefighters denied or were inconsistent on whether a head wound was observed or treated.
Firefighters reported altered consciousness and constricted pupils. They applied oxygen to the patient at 25 liters per minute. The patient fought the mask and vomited. Firefighters reduced the oxygen level and the patient reportedly is less agitated. Firefighters disagreed whether there was an odor of alcohol, while one firefighter indicated a strong odor of alcohol. Civilian witnesses at the patient's side reported that they did not observe an odor of alcohol. The amount of vomiting is described as minor by witnesses, while at least one firefighter described it as more extensive and recurring.
Firefighters were inconsistent on who did what part of the exam on the patient, but agreed that no one firefighter conducted a complete assessment of the patient. The patient was not immobilized prior to movement. The patient was not considered a potential diabetic patient because he did not have a Medic Alert or other medical tag or bracelet.
21:37 — Police unit 2021, which included a training officer and trainee, indicated that they will take the call. Unit 2022 continued to the scene but remained available for call. While on-scene, police did not take any statements, investigate the apparent robbery, or write a report following the call. Upon arrival, officers were advised by a firefighter that the patient was just an "ETOH"(the chemical name for ethanol) indicating an intoxicated individual.
21:40 — Ambulance 18 again advised it was en route. Engine 20 crew continued with patient assessment. There is an inconsistency among firefighters about whether vital signs were written down, on glove or paper, and by whom. The description of the patient included "pin-point" pupils and a Glascow Coma Scale score of "less than 8." (The OIG report does not include actual values).
21:53 — Ambulance 18 arrived on scene. They are advised by firefighters that the patient is "ETOH." Neither ambulance EMT examines the patient. The ambulance crew did not recall receiving any vital signs or information on head injury or coma scale values.
21:58 — Ambulance 18 departed scene. Driver refused to go to nearest hospital and elected to go to Howard Hospital, but left in the wrong direction, which added 5 minutes to the transport. The OIG report suggests that the reason for not going to the nearest hospital was that the driver had personal business in the Howard area. Firefighters returned to station, but did not complete any record of the call. Station log books examined by the OIG are said to appear to contain information added at a later date.
Arrival at Hospital
22:18 — Ambulance 18 arrived at the Howard Hospital ED. The ED was understaffed; all treatment rooms were occupied and stretchers were in the halls.
22:30 — Triage nurse signed in patient with chief complaint of ETOH and that he had "fallen" on the street. Triage nurse reports that she did not assess the patient because he was "asleep" and was told the patient was intoxicated. Coma scale score, pupils, skin integrity, and breath sounds were not assessed. Temperature was abnormally low. Triage notes show patient awake and alert, although nurse stated he was "asleep." Patient was placed in the hallway.
22:36 — Triage reported to charge nurse that patient was ETOH, not in distress, fell asleep, was upright on stretcher, not talking, had a normal pulse oxymetry, and was classified as level 3. On the basis of non-ambulatory or history of fall or intoxication the patient would be level 2 under the triage protocol. Unconscious would have been level 1 under the protocol.
23:00 — Physician maintained that she gave patient complete assessment. This time contradicts all other records. The physician told the OIG that the patient was white male, had vomit on face and blanket, was unkempt, and looked like typical alcoholic. She advised that she performed a head-to-toe assessment, found no injuries; patient was slumped, unresponsive, not talking, pupils were fine. All physician notes in record were illegible.
January 7, 2006
24:00 — Nurse taking another patient to a room passed Mr. Rosenbaum and noticed that Mr. Rosenbaum's breathing was characterized as a snoring, growling noise. No assessment since 22:36 although protocol required reassessment every 15 minutes. Nurse applied sternal rub, which produced inward posturing of limbs. Nurse observed that the patient had torn rear pants pocket, an expensive wrist watch, and a head laceration. The physician was notified, the patient was taken to the resuscitation room where it was observed that pupils were unequal and sluggish and breathing was shallow. Head injury was suspected. Patient placed on long spine board.
00:15 — Trauma team assumed care of patient.
Later that day, reports were received by police that Mr. Rosenbaum's credit cards had been used by an unauthorized person.
January 8, 2006
Mr. Rosenbaum died from head injuries sustained in an assault and robbery.
OIG Official Assessment
Although the OIG's report contains lengthy findings about the substandard service that was provided by police, fire, EMS, and Howard Hospital, and suggested many improvements, the following statement is the ultimate finding of the investigation.
"These multiple individual failures during the Rosenbaum emergency suggest alarming levels of complacency and indifference, which, if systemic, could undermine the effective, efficient, and high quality delivery of emergency services to District residents and visitors," Charles J. Willoughby, Inspector General wrote in his transmittal letter.
EMTALA Issues Rampant
Although the Centers for Medicare and Medicaid Services (CMS) report on its investigation has not been released, the Inspector General's report shows a number of critical EMTALA issues, issues that had they been addressed would have stopped the failure cascade two hours sooner, and perhaps could have prevented the fatal outcome.
Under CMS patterns of enforcement, citations would be likely for:
1. Failure to promptly provide triage at 22:18 – possible "parking" of the patient as warned against by subsequent CMS memo;
2. Failure to conduct a standard assessment per protocol;
3. Failure to properly classify the patient per triage protocol;
4. Failure to provide timely medical screening examination;
5. Failure to provide stabilizing care in a timely manner;
6. Failure to periodically reassess the patient per protocol
7. Failure to properly document compliant care, record illegible;
8. Possibly a conclusion that false information was provided by one or more hospital personnel.
Although the ED was busy, CMS probably would not allow that to excuse basic compliance standards, and also could raise the issue of adequate staffing under the Medicare Conditions of Participation.
The Ultimate Root Cause
While there are many elements of substandard performance addressed by the IG's report, there is one fundamental root-cause element that runs consistently through this entire case: a failure to consider patients with an odor of alcohol as "real patients."
This basic prejudice is pervasive in many EDs in the country, such that this exact episode could occur in almost any hospital in any community in the United States.
This tendency to afford delayed or substandard care to patients perceived as drunk or intoxicated has existed for my entire EMS/ED law career. It was substantial enough in 1988 that EMTALA was amended to include symptoms of substance abuse as a specific category of emergency medical condition and, thereby, mandate appropriate care for "drunks and druggies" in every ED in the country.
The force of this common prejudice is evident in the physician's description of the patient in terms that totally conflict with the objective view of concerned witnesses at the scene. This middle class professional who "looked like he belonged" in the good neighborhood, wore an expensive watch, and with a Glascow Coma Scale score of less than 8 was viewed by the physician as a typical unkempt, dirty, intoxicated alcoholic on the basis of four simple letters E-T-O-H.
On the basis of the IG's report, it appears that those same four letters prevented police, fire, and EMS personnel from considering the case serious from the beginning. Those letters appear to have lured a busy triage nurse into several critical errors that delayed Mr. Rosenbaum's care for hours. Those letters allowed good nurses and physicians to walk past Mr. Rosenbaum as he deteriorated without even really noticing him for hours.
Conclusion
EMTALA requires possibly intoxicated patients to first be screened to determine whether they have any medical, toxic, or traumatic conditions that might have caused or might be masked by the apparent intoxicated state. Citations have been issued for discharges before a patient's sobriety level reached a point where reliable neurological assessments can be performed.
From an EMTALA compliance perspective and from a medical malpractice exposure, patients who are perceived as intoxicated represent a significant risk to hospital EDs, EMS, and police agencies. Failure to appreciate this fact can and will result in catastrophic events like the Rosenbaum case.
It is the legal responsibility of hospitals and ED personnel to ensure that ETOH is not accepted as a diagnosis from the field, is not allowed to affect care in the ED, and is considered an elevated risk element in all presenting patients. No one should die in a U.S. hospital because he/she had wine with dinner.
References
1. Government of the District of Columbia Office of the Inspector General. Summary of Special Report: Emergency Response to the Assault on David E. Rosenbaum. OIG No. 06-I-003-UC-FB-FA-FX. June 2006.
On January 6, 2006, well-known Washington, DC, journalist David Rosenbaum had wine and dinner with his wife, then picked up his music player and headphones and went out for a walk.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content