You can learn from this difficult EMTALA case
An algorithm can be used for basic decision making within the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations and in sorting through difficult EMTALA situations as they occur, says according to Todd Taylor, MD, FACEP, an attending ED physician at Good Samaritan Regional Medical Center in Phoenix.
Algorithms tend to break down, however, when difficult situations arise, Taylor acknowledges. "Judgment calls must be made at decision points in the algorithm that could completely change the process," he notes.
Taylor provides the following case study that illustrates the way the algorithm is used in the decision-making process. (The bracketed points are taken from the algorithm included in the full PDF issue.)
A 43-year-old electrician sustained a 220-volt shock when he stood up and contacted a bare wire across his upper back. The ground point consisted of both hands as he was holding onto a metal bar. He arrived by ambulance to a level I trauma center (Hospital A), but as a "routine" ED patient.
The patient was quickly evaluated and noted to have second- to third-degree burns across the upper back and palms of the hands. Both arms were "dusky," beginning to swell, but pulses were present. A trauma consult recommended transfer to the regional burn center.
The patient had arrived at the hospital and, even if he had been unconscious, there would be an implied request for medical care [arrived and requests care = yes]. The patient was triaged, logged, and registered simultaneously. Note that the medical screening examination was not delayed by any of those procedures.
An initial medical screening examination by the emergency physician revealed an emergency medical condition (EMC), and a trauma consult was obtained to assist in the evaluation [EMC = yes].
The trauma consult determined that, while the facility was a level I trauma center and beds were available [capacity = yes], it did not have specialized capability in burn care [capability = no]. If capacity and/or capability are a "no," then this decision point is "no" [capacity = yes, capability = no, therefore, final answer = no].
The transfer procedure was initiated with the anticipation that the patient would be transferred to the regional burn center at another local trauma center (Hospital B). The patient was advised of this recommendation but refused transfer to that hospital because, "my father died there, and I refuse to be treated at that hospital" [consent to transfer = no].
The patient was advised of the seriousness of his injury and the need for specialized care but still refused transfer to Hospital B. A "transfer refusal form" was offered, which he refused to sign (documentation was made to that effect in the patient’s chart), and he declined to leave against medical advice [request to leave AMA = no].
The trauma service was contacted again and informed of the patient’s refusals. The trauma attending refused to accept the patient for admission and requested a psychiatric consult to declare him "a danger to self" and to obtain a court order to force the transfer.
Call local EMTALA resources’
The algorithm ends at this point, because such unanticipated events cannot be accounted for in an algorithm, says Taylor. "Whenever such an event occurs, it should prompt a call to local EMTALA resources," he advises.
This resource may be a hospital administrator (EMTALA compliance officer), risk management, or an EMTALA expert if available, says Taylor. "It is also possible that hospital policies might help deal with the situation," he notes. "But for the same reasons as mentioned in the algorithm limitations, hospital policies may be insufficient for every eventuality."
In this case, Taylor was contacted initially as a local EMTALA expert, and he recommended the following actions:
• Contact the chief of trauma.
• Contact risk management.
• Contact the hospital administrator on call.
• Advise the patient that every effort to comply with his wishes would be made, but that his continued refusal to be transferred to a higher level of care could delay life- and limb-saving treatment. Documentation of those actions was made in the chart.
This case was resolved by offering the patient two options:
1. The patient could stay, possibly lose both arms, or even die. The trauma service continued to refuse to accept the patient for admission, and plans were made to admit the patient to the "ICU service." Had the patient not been accommodated somehow, a potential EMTALA situation would have occurred for Hospital A. The on-site trauma surgeon was clearly in violation of hospital policy and possibly EMTALA, Taylor says. The political realities of the situation were dealt with through the hospital committee structure.
2. Ongoing attempts could be made to identify an alternative burn center in another region. Two alternatives were identified, one 250 miles (Hospital C) and one 550 miles (Hospital D) away. The closer hospital was contacted, and the burn unit director refused to accept the patient in transfer due to the situation (i.e., there was a closer center available).
Under EMTALA, the patient’s refusal to go to Hospital B does not matter. In fact, that hospital was never contacted. Ultimately, the hospital administrator at Hospital C overrode the burn unit director’s decision, accepted the patient in transfer, and averted an EMTALA situation.
At this point, you can return to the algorithm to the "Patient requests to be transferred?" box and complete the transfer procedure, Taylor explains.
While this case is difficult, it is not uncommon, he points out. "It illustrates when a situation falls off’ the algorithm, it is prudent to get additional EMTALA help."
In this case, at least two potential EMTALA violations were avoided, Taylor notes. "Knowing your EMTALA resources is more important than knowing the EMTALA algorithm," he notes, "but the structure of the algorithm may assist in resolving many EMTALA situations."
Sources
• Denise Casaubon, RN, DNR Medical-Legal Consultants, 16217 Balsam Drive, Fountain Hills, AZ 85268. Telephone: (480) 816-6695. Fax: (480) 836-8185. E-mail: [email protected].
• Todd B. Taylor, MD, FACEP, 1323 E. El Parqué Drive, Tempe, AZ 85282-2649. Telephone: (480) 731-4665. Fax: (480) 731-4727. E-mail: [email protected].
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