EMTALA / JCAHO violation?
- Thread starter HawkMedic
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I'm just trying to prepare for a confrontation with the system director, so this doesn't happen again. If I'm at fault than so be it. I've heard alot of good comments, and I appreciate all the comments some are a bit over the top but it's still information to take home at the end of the day. Again I didn't find what I was looking for with the web search but I guess I'll try it again.
For EMTALA: appropriate assessment by qualified (usually Physcian) person, stabilization, transfer arrangements with the most appropriate facility who will accept the patient and transfer by the most appropriate team.
An ALS team can refuse a patient for transfer if it is outside of their scope.
For JCAHO, a hospital must have a transfer policy in place. For your argument, you should respectfully request a copy from the ER Manager before your meeting. Hospital staff do not like to be left hangin' themselves out on a limb either on a transport depending on some of your equipment and meds either. They may no have provisions to go on your ambulance like a separate narc box. Their pharmacy gets a little upset if just a handful of meds are pulled for a transport. If they need more meds and you don't carry it, the patient is screwed anyway. Most hospitals don't lend their equipment out either since they don't know your abilities. You may think something looks easy enough but you hang yourself, the patient and the hospital when you :censored::censored::censored::censored: it up on the road in the middle of nowhere.
An ALS team can refuse a patient for transfer if it is outside of their scope.
For JCAHO, a hospital must have a transfer policy in place. For your argument, you should respectfully request a copy from the ER Manager before your meeting. Hospital staff do not like to be left hangin' themselves out on a limb either on a transport depending on some of your equipment and meds either. They may no have provisions to go on your ambulance like a separate narc box. Their pharmacy gets a little upset if just a handful of meds are pulled for a transport. If they need more meds and you don't carry it, the patient is screwed anyway. Most hospitals don't lend their equipment out either since they don't know your abilities. You may think something looks easy enough but you hang yourself, the patient and the hospital when you :censored::censored::censored::censored: it up on the road in the middle of nowhere.
lightsandsirens5
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Be nice people....and remember, there is a "No legal advice" rule here on the forum.
lightsandsirens5
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OP, are you a medic or a basic? What about your partner?
Did you guys get a 12 lead, or just a 3? I am asking because if you are a basic you probably have an excuse for transporting to the closest ER since sans 12 lead you don't know what is going on. No, that being said, you should be going off clinical presentation regardless of what the 12 lead shows and if the patient was truly "hemodynamically unstable" he should have been pounded via fastest transfer method to a facility equipped with an operational cath lab, be that in your ambulance or with HEMS.
Additionally, I would say, be advised that if you ask a question on this site, expect people to ask for information. Especially when you give very little. There are lots of people on here that are critical thinkers, as they should be, that like to make informed decisions and formulate informed opinions. Give the info needed to let others formulate the answer you are seeking. If you don't want to give out information, don't ask questions that require it.
Did you guys get a 12 lead, or just a 3? I am asking because if you are a basic you probably have an excuse for transporting to the closest ER since sans 12 lead you don't know what is going on. No, that being said, you should be going off clinical presentation regardless of what the 12 lead shows and if the patient was truly "hemodynamically unstable" he should have been pounded via fastest transfer method to a facility equipped with an operational cath lab, be that in your ambulance or with HEMS.
Additionally, I would say, be advised that if you ask a question on this site, expect people to ask for information. Especially when you give very little. There are lots of people on here that are critical thinkers, as they should be, that like to make informed decisions and formulate informed opinions. Give the info needed to let others formulate the answer you are seeking. If you don't want to give out information, don't ask questions that require it.
18G
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OP... do you not provide pre-notification or speak to a medical command physician at the receiving hospital regarding patient's you are deeming to be unstable while you're enroute?
Why didn't you consult and inquire about facility destination? Just curious.
As far as EMTALA... the sending hospital must ensure that appropriate staff and equipment are present for patient transfer. If a nurse was needed and no other capable providers were available, legally they must send the nurse.
Why didn't you consult and inquire about facility destination? Just curious.
As far as EMTALA... the sending hospital must ensure that appropriate staff and equipment are present for patient transfer. If a nurse was needed and no other capable providers were available, legally they must send the nurse.
To answer some of the questions: I am an NREMT-I99; We have paramedics/ CRT-I's in the county. All of the county is volunteer with the exception of the supplemental paid staffing; So we rely on the volunteers to upgrade as driver most of the time. Occasionally we have a chase vehicle from the paid service upgrades. On this call I only had a first responder with limited expiriance (so basically just a driver). The patient presented with cardiogenic shock symptoms, along with (JVD, mild hypoxia, dyspnea, dizziness, urinary incontinence and syncope). I'm with Usalsfyre on the appropriate transport facility, however in the short period of time its difficult to know that in the 15 minutes with the patient is the symptoms going to improve or deteriorate. Luckly it wasn't an AMI, and the patients condition did improve. I did consult with the facility, and we transmitted the ECG to the other facility for diagnosis which they thought it was a STEMI. I hope that answers most of the questions! I'll try to remember not to be so vague in the future.
I guess the other question I would ask is in the idea of transporting to the appropriate facility would you work an arrest by yourself? The variables are endless, and this case just proves the point that its called "practicing medicine". You'll probably never master it, even though I'm sure there are para-gods out there. And opinions are like :censored::censored::censored::censored::censored::censored::censored:s everyones has one. Its good to have some collected critism to balance things out though, and I do respect the views that everyone is bringing to this forum.
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Usually, ALS is synonomous with a paramedic, but we won't quibble.
But I am going to offer you a constructive professional observation.
You do not seem to be comfortable with what makes a patient stable or unstable.
It looks like you were overly concerned with "what if" than what you had. As time went on, you became more uncomfortable to the point of refusing a transfer that you caused by not going to the appropriate facility.
The initial hospital looks like they were trying to bail you out by treating the patient as much as possible so you would have no issues on your trip.
It has been my observation and I admit I was the same way, that before I started seeing large amounts of truly unstable patients, that providers just don't have a good idea on what exactly unstable is.
Your question about "would you work this code alone?" It wouldn't be the first time. But consider, you are going to need help. So your driver is going to have to pull over and do CPR. Because CPR and defib is what you need until help arrives.
If you drop a patient off at a hospital that cannot provide the needed treatment and the patient dies the outcome is no different than if he dies in your truck on the way to some place that can help.
Just like with trauma, it actually causes more delays and worse outcomes when you don't go to the trauma facility.
In fairness there are times when the closest facility is the right answer, but to put some perspective to that, in my whole career, in multiple states and countries, only 1 time have I ever encountered such a case.
I will also qualify that it was basically the perfect storm of things that could go wrong. From inclimate weather prohibiting airmed, to a VFD that left the patient in the car uposide down in a ditch filling up with water because they were afraid of causing a secondary c-spine injury, an inexperienced partner, equipment failures, etc.
I would suggest you ask to spend spend some time in the regional ICU in order to become more comfortable identifying and managing critical patients.
TomB
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You couldn't find a lot of resources about it? The search term "EMTALA" yields over 55,000 results. Front page hits include Wikipedia, CMS, ACEP, etc. So astonish me. Where did you look?
I don't know if the OP even looked, but i would just like to point out that in almost all of the EMTALA websites I have visited, there is usually some sort of disclaimer that says many of the tennants are open for legal interpretation and advice or information given is meant to serve as a guide rather than definitive rule.
I would stipulate that an EMS provider, who is also taught curriculum in terms of black and white, right and wrong, may not be proficent enough to extrapolate the needed information.
I have even had arguments with physicians on this very website who have been taught certain interpretations by people they respect, trust, and maybe admire were black and white and had to be challenged that multiple interpretations on the topics was debatable and often a matter of local procedure rather than fact.
zmedic
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EMTALA basically says if someone shows up at your ER you must:
1: Do a medical screening exam.
2: Treat life threatening conditions and stabilize the patient
3: Transfer in appropriate fashion. (Ie patient unlikely to deteriorate enroute, patient consented to transfer, patient has been accepted by MD at receiving facility etc)
If you show up with a patient that my hospital can't handle, it's an EMTALA violation for me to say "I'm not treating this patient, take them somewhere else." It isn't a violation for me to say "I'll treat this patient, but you should not have brought the patient here because we aren't a trauma center/don't have OB/GYN/are not a pediatric hospital/ whatever."
Also if your ambulance service is going to bring patients to a hospital that isn't full service, there needs to be a system in place for how transfers are going to happen. It shouldn't be a surprise to the ER if you can't transfer a patient on a vent, on pressors etc.
1: Do a medical screening exam.
2: Treat life threatening conditions and stabilize the patient
3: Transfer in appropriate fashion. (Ie patient unlikely to deteriorate enroute, patient consented to transfer, patient has been accepted by MD at receiving facility etc)
If you show up with a patient that my hospital can't handle, it's an EMTALA violation for me to say "I'm not treating this patient, take them somewhere else." It isn't a violation for me to say "I'll treat this patient, but you should not have brought the patient here because we aren't a trauma center/don't have OB/GYN/are not a pediatric hospital/ whatever."
Also if your ambulance service is going to bring patients to a hospital that isn't full service, there needs to be a system in place for how transfers are going to happen. It shouldn't be a surprise to the ER if you can't transfer a patient on a vent, on pressors etc.
rezmedic
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Emtala
I get into a lot of discussions about EMTALA and your original situation, which to me are two separate discussions. EMTALA is about dumping patients without continuity of care, by the way I interpreted the explanation. It means you can't drop a patient off somewhere without the receiving facility assuming care. It seems to be grossly misunderstood, or I'm off base. Perhaps someone can better explain it than that. I've had MD's try to tell me according to EMTALA we can't have patient's from the same car and same car accident in the same ambulance. ?
The second part of the original comment is that when we have unstable patients, or think we do, do we take them to the closest facility, or to the most appropriate one. I will freely admit I'm often questioned about my decisions on this. I have many times watched the service I volunteer with wait 40+ minutes for a helo rather than get into the ambulance and drive 35 minutes to the better choice. Our other option is the medical clinic 10 miles away with a nursing home attached and an "ER" and I use that term loosely. They don't have a doctor nights and weekends, and most of them refuse to come in until the RN on duty has evaluated the patient. In a real emergency I never take patients there unless the patient absolutely refuses to go anywhere else. They just end up buying 2 ER visits instead of 1. It always seems to me that the people who don't want to go the 35-40 minutes to better care are less concerned with their patient than with their own lack of confidence in their skill set. Too many EMT's forget that ALS starts with BLS. I probably oversimplify but I will always try to get the patient to the right facility the first time.
I get into a lot of discussions about EMTALA and your original situation, which to me are two separate discussions. EMTALA is about dumping patients without continuity of care, by the way I interpreted the explanation. It means you can't drop a patient off somewhere without the receiving facility assuming care. It seems to be grossly misunderstood, or I'm off base. Perhaps someone can better explain it than that. I've had MD's try to tell me according to EMTALA we can't have patient's from the same car and same car accident in the same ambulance. ?
The second part of the original comment is that when we have unstable patients, or think we do, do we take them to the closest facility, or to the most appropriate one. I will freely admit I'm often questioned about my decisions on this. I have many times watched the service I volunteer with wait 40+ minutes for a helo rather than get into the ambulance and drive 35 minutes to the better choice. Our other option is the medical clinic 10 miles away with a nursing home attached and an "ER" and I use that term loosely. They don't have a doctor nights and weekends, and most of them refuse to come in until the RN on duty has evaluated the patient. In a real emergency I never take patients there unless the patient absolutely refuses to go anywhere else. They just end up buying 2 ER visits instead of 1. It always seems to me that the people who don't want to go the 35-40 minutes to better care are less concerned with their patient than with their own lack of confidence in their skill set. Too many EMT's forget that ALS starts with BLS. I probably oversimplify but I will always try to get the patient to the right facility the first time.
If I am not mistaken, there is a compassionate care clause to #3 which would negate the patient unlikely to deteriorate enroute clause?
Best, most non-judgmental post in the whole thread.
The only thing I would say to the OP is that with this crowd, try and get all the facts out there in your initial post. It was like pulling teeth to get everything needed to form an opinion.
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zmedic
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Veneficus; said:
There is a lot of grey areas that I don't pretend to be an expert on. Like what happens if you have a patient with a brain bleed who needs neurosurgery, but you don't have that ability at your ER. But the patient is actively herniating and you think they are going to deteriorate enroute. Can you transfer them? You are sending them to definitive care?
Not sure.
I think it's worth remembering that many people think they know about HIPPA, or EMTALA, and they are talking out of their butt. But educating them in the heat of battle usually doesn't work.