EMTALA / JCAHO violation?

[HawkMedic]

I had a call the other day for a person with a syncopal episode, however presenting with some ACS symptoms. 12 lead performed with Junctional Rythmn/ RBBB (and what the hospital is calling an Inferior Infarct). Patient is unstable so we transported to the local facility only to have our heads nearly ripped off by the charge nurse, even after explaining the nature of the call. Patients subsquent 12 leads do not show any signs of an AMI/ STEMI, and patient refuses chest pains/ pressure throughout the call. Basically poor diagnosis on the part of the hospital (my opinion), then they treated the patient and tried to get EMS to perform an interfacility w/ heparin, and tridol bolused. EMS advised they would need a nurse to transport with the patient. They refused so EMS refused. Who is right, and is there any violation that has occurred. (Outcome of patient: No STEMI/ AMI; Troponin, CPK and CK are all normal; Patient refused catherization at cath lab) Patient is now suffering from issues associated with heparin administration. Patient was on coumadin at the time.

 

[usalsfyre]

So you took the patient to an inappropriate facility, didn't have the education or equipment to deal with the subsequent transfer it created and then tried to get the hospital to bail you out by sending a nurse who's probably unfamiliar with the transport environment along for the ride, and are pissed off because they refused? Did I get all that?

"Unstable" patients don't get "stable" in the ED, especially of an inappropriate facility. Medics need to grow a pair and go to the right place.

 

[Christopher]

Patient is unstable so we transported to the local facility...

Let's consider a best case scenario assuming he was having a fat-daddy MI; we'll assume your local hospital is right down the road and the big medical center is 45 minutes away:

• Minimal scene time = 5 minutes
• Distance to Bandaid Station (Local Hospital) = 5 minutes
• Unloading + Handoff = 5 minutes
• Physician Evaluation and Orders = 5 minutes
• Stat Labs = 10 minutes
• Additional stabilization interventions = 20 minutes
• Organization of Critical Care Transfer = 0 minutes (you guys were there)
• Loading of patient = 5 minutes
• Driving to Level 1 Trauma/Neuro/Pediatric/Astronaut Care Center = 45 minutes
• Unloading + Handoff = 5 minutes
• Physician Evaluation and Orders = 5 minutes
• Trip to cath lab = 5 minutes
• Procedure Start to Balloon Inflation = 10 minutes

I count 125 minutes from arrival on scene to definitive care, potentially 50 minutes arrival to fibrinolytics.

If you instead went directly to the Big Mamma Jamma Center the patient would receive definitive care in approximately 90 minutes. Even better would be transmission of the 12-Lead while enroute to get the Physician's overread, if you're not interpreting the 12-Lead, which could activate the STEMI system shaving perhaps 10-20 minutes at the receiving facility.

For just about every urban and suburban system, favor bypassing to the appropriate facility over pit stopping at a bandaid station.

Moreover, it sounds like your dude had a Stokes-Adams attack, worsening intraventricular conduction defects, or is experiencing Sick-Sinus-Syndrome and potentially needs a stat pacemaker. You've got a transcutaneous pacer available anyways.

Either way, I'm with usalsfyre...we're Paramedics and can handle an "unstable" cardiac patient as well as any community hospital...usually better!

 

[Aidey]

I had a call the other day for a person with a syncopal episode, however presenting with some ACS symptoms. 12 lead performed with Junctional Rythmn/ RBBB (and what the hospital is calling an Inferior Infarct). Patient is unstable so we transported to the local facility only to have our heads nearly ripped off by the charge nurse, even after explaining the nature of the call.

How was the pt unstable?

 

[silver]

I had a call the other day for a person with a syncopal episode, however presenting with some ACS symptoms. 12 lead performed with Junctional Rythmn/ RBBB (and what the hospital is calling an Inferior Infarct). Patient is unstable so we transported to the local facility only to have our heads nearly ripped off by the charge nurse, even after explaining the nature of the call. Patients subsquent 12 leads do not show any signs of an AMI/ STEMI, and patient refuses chest pains/ pressure throughout the call. Basically poor diagnosis on the part of the hospital (my opinion), then they treated the patient and tried to get EMS to perform an interfacility w/ heparin, and tridol bolused. EMS advised they would need a nurse to transport with the patient. They refused so EMS refused. Who is right, and is there any violation that has occurred. (Outcome of patient: No STEMI/ AMI; Troponin, CPK and CK are all normal; Patient refused catherization at cath lab) Patient is now suffering from issues associated with heparin administration. Patient was on coumadin at the time.

Why was a nurse needed in your opinion?

 

[Veneficus]

So you took the patient to an inappropriate facility, didn't have the education or equipment to deal with the subsequent transfer it created and then tried to get the hospital to bail you out by sending a nurse who's probably unfamiliar with the transport environment along for the ride, and are pissed off because they refused? Did I get all that?

"Unstable" patients don't get "stable" in the ED, especially of an inappropriate facility. Medics need to grow a pair and go to the right place.

Well said.

 

[Veneficus]

Let's consider a best case scenario assuming he was having a fat-daddy MI; we'll assume your local hospital is right down the road and the big medical center is 45 minutes away:

• Minimal scene time = 5 minutes
• Distance to Bandaid Station (Local Hospital) = 5 minutes
• Unloading + Handoff = 5 minutes
• Physician Evaluation and Orders = 5 minutes
• Stat Labs = 10 minutes
• Additional stabilization interventions = 20 minutes
• Organization of Critical Care Transfer = 0 minutes (you guys were there)
• Loading of patient = 5 minutes
• Driving to Level 1 Trauma/Neuro/Pediatric/Astronaut Care Center = 45 minutes
• Unloading + Handoff = 5 minutes
• Physician Evaluation and Orders = 5 minutes
• Trip to cath lab = 5 minutes
• Procedure Start to Balloon Inflation = 10 minutes

I count 125 minutes from arrival on scene to definitive care, potentially 50 minutes arrival to fibrinolytics.

If you instead went directly to the Big Mamma Jamma Center the patient would receive definitive care in approximately 90 minutes. Even better would be transmission of the 12-Lead while enroute to get the Physician's overread, if you're not interpreting the 12-Lead, which could activate the STEMI system shaving perhaps 10-20 minutes at the receiving facility.

For just about every urban and suburban system, favor bypassing to the appropriate facility over pit stopping at a bandaid station.

Moreover, it sounds like your dude had a Stokes-Adams attack, worsening intraventricular conduction defects, or is experiencing Sick-Sinus-Syndrome and potentially needs a stat pacemaker. You've got a transcutaneous pacer available anyways.

Either way, I'm with usalsfyre...we're Paramedics and can handle an "unstable" cardiac patient as well as any community hospital...usually better!

You forgot to add time to call a physician at the receiving facility and arrange appropriate transfer of care. Otherwise instead of a direct admit to interventional cardio, radio, or whoever is running the cath lab, that pt will be re-evaluated in the receiving ED adding further time.

I also think you are overly generous in your evaluation estimates. Probably add at least another 10 minutes to them, plus time for radiology and labs.

 

[Christopher]

You forgot to add time to call a physician at the receiving facility and arrange appropriate transfer of care. Otherwise instead of a direct admit to interventional cardio, radio, or whoever is running the cath lab, that pt will be re-evaluated in the receiving ED adding further time.

I also think you are overly generous in your evaluation estimates. Probably add at least another 10 minutes to them, plus time for radiology and labs.

I should have bolded "best case" The radiologist was in the ED for free doughnuts and the lab technician got a gift card that AM from the ED Nurses.

 

[exodus]

I don't understand is why you are jumping Hawk's butt. He interpreted the 12 lead to not be an MI so he did transport to a fully capable hospital that just had dumbasses for staff. The dumbass comment is reinforced by the fact he was refused cath.

 

[Aidey]

The issue is that he claimed the patient was an unstable cardiac patient, and that is why they transported to the closer, less capable hospital. Then when the hospital attempted to transfer the patient to the more capable hospital EMS threw a fit and demanded a RN accompany them due to medications that are normally well within the paramedic scope.

 

[Handsome Robb]

EMS threw a fit and demanded a RN accompany them due to medications that are normally well within the paramedic scope.

For what it's worth we'd have to call for a CC-P with a pump to take this transfer. Only our CC-Ps can take Heparin drips, partially because they are the ones with pumps. 911 trucks don't have 'em and the hospitals here would burn to the ground before they let us take one of theirs.

 

[DesertMedic66]

The issue is that he claimed the patient was an unstable cardiac patient, and that is why they transported to the closer, less capable hospital. Then when the hospital attempted to transfer the patient to the more capable hospital EMS threw a fit and demanded a RN accompany them due to medications that are normally well within the paramedic scope.

For my area ALS could not do that transport. We would need either the hospitals nurse to ride with us and continue patient care or we would have to call in one of our nurses and get the CCT rig ready (at least 60 minutes).

 

[Veneficus]

For my area ALS could not do that transport. We would need either the hospitals nurse to ride with us and continue patient care or we would have to call in one of our nurses and get the CCT rig ready (at least 60 minutes).

So the long and short if it is what USALS said, don't go to a facility that cannot handle the patient.

 

[Aidey]

The OP said the meds were bolused. There may not have been a drip running.

Edit: I also concur with the idea that you shouldn't take a patient to a facility that can't handle them, and don't be surprised when they get pissed off when you do.

 

[silver]

The OP said the meds were bolused. There may not have been a drip running.

Thats what I thought as well. In my experience in the cath lab we usually received transfers and ED patients that were loaded with ASA, clopidogrel, and heparin bolus. We sometimes got drips. For any interventions the physicians would bolus and then run a drip with bivalirudin most of the time, because it could get your PTT up in literally minutes (or time it took to prepare for an intervention).

 

[usalsfyre]

I don't understand is why you are jumping Hawk's butt. He interpreted the 12 lead to not be an MI so he did transport to a fully capable hospital that just had dumbasses for staff. The dumbass comment is reinforced by the fact he was refused cath.

What was a facility without interventional cardio capability (good for more than just STEMIs BTW) going to do with an unstable cardiac patient? Classic EMS "don't die in my truck" dump and run.

No violation of EMTALA, but a jackass move on EMS's part.

 

[HawkMedic]

I'm glad to her the opposition; I'm just doing the job I am required to do! The patients condition being hemodynamically unstable is what caused the transport unit to goto the local facility which is protocol. The patient did not require a cardiac intervention center. I'm an NREMT-I not a paramedic, and my question is solely if the ER is refusing to except the patient and wishes for EMS to transport than is this an EMTALA, or JHACO violation?

 

[HawkMedic]

Silver to reply to you; I cannot transport Heparin, or Tridol; It's outside my scope of practice!

 

[Christopher]

I'm glad to her the opposition; I'm just doing the job I am required to do! The patients condition being hemodynamically unstable is what caused the transport unit to goto the local facility which is protocol. The patient did not require a cardiac intervention center.

Protocols are guidelines. Would a post-arrest patient with a BP of 70/40 be "hemodynamically unstable" and have to go to the local facility? Or would they go to the appropriate facility...food for thought.

I'm an NREMT-I not a paramedic, and my question is solely if the ER is refusing to except the patient and wishes for EMS to transport than is this an EMTALA, or JHACO violation?

The ED cannot refuse to accept a patient brought in by EMS unless they are on Full Diversion...which even then that would be a giant gray area. EMS would likely win on that one.

You can, however, refuse to accept a patient for transfer if you believe the patient is outside your scope of care or if the patient requires interventions/medications you cannot legally perform/administer.

 

[Veneficus]

Protocols are guidelines. Would a post-arrest patient with a BP of 70/40 be "hemodynamically unstable" and have to go to the local facility? Or would they go to the appropriate facility...food for thought..

I would ask if EMS would take a patient requiring a trauma surgeon to a center that didn't even have a surgeon if he was unstable?

In my home state, the dept of public safety actually had to codify trauma transport criteria.

EMS will never be a profession if they can't even figure out to take trauma patients to a trauma center and cardiac patients to a cardiac center.

If I started asking people on the street if they would take a trauma patient to a trauma center or a hospital that doesn't have trauma, (substitute cardio, neuro, etc as you like) I bet most of them would guess the right answer.

Why do we have to even tell EMS people this?