Private Hospital dictating Pt care

[swmedic]

Epi-do,
That is right. If I have a code STEMI, verified by 12-lead, they want me to bring this pt. to them even though they do not have the capabilities to do open heart or CATH. I can have this pt in an "appropriate" hospital in no more than 30 mins in most cases. If i am further than that then I can see coming to them first, but how much more time will be lost going there first and then transporting to the appropiate hospital! Long bone fractures are another problem. The ortho that covers the local hospital refuses to come in. He wants them in a soft cast until they can come into his office, so if the pt needs surgery, they have to be transported to a different hospital. Just seems like trying to do what's right for the pt is becoming more difficult because this hospital wants to get some of the money they are losing. I am not a newbie...I have over 15 years as a medic and can usually tell whats going to end up at a higher level of care. So my main question is not what I should do, but has anyone ran into legalities concerning this type of problem.

 

[redcrossemt]

EMTALA only states that the hospital must assess the pt with an emergency, when they are "presented to the facilities Emergency Dept." It does not mean, when you are on hospital grounds.

Actually, this is not true. EMTALA is much more extensive. This is all from 42 CFR 489.24e...

1. The patient must be on the grounds of a hospital facility, which includes the campus of the facility up to 250 yards from the main contiguous buildings or ER, or a facility-owned air or ground ambulance. (There is case law that enforced this ruling regarding a patient that was on the grass on the hospital's campus.)

2. The patient, or someone acting on their behalf, must ask a healthcare worker at the facility (including outpatient offices on campus) for screening for a medical condition. (There is case law that enforced this ruling regarding someone else asking for a screening on behalf of the patient.)

If you are destined for a different facility as required by EMS protocols for your area, then EMTALA applies to the destination facility once you arrive, not any of the facility campuses you may drive through on the way there.

 

[triemal04]

swmedic-

Check the laws in your state. It varies, but in some places it is legally permissible and essentially you are legally obligated to take some pt's (trauma pt's in most cases) to the closest appropriate and available hospital even if that means bypassing one. For example, if your local hospital is 10 miles away and a trauma center is 20, if the pt meets the criteria it's appropriate to go to the trauma center.

Unfortunately, if your medical director is dictating that you always go to the local hospital you are in a bind. Research the law where you are, and the multiple studies that have shown that taking someone to the appropriate hospital and bypassing a closer one is beneficial; there's plenty, then bring it up with him with as much documentation and facts as you can find. Just be aware that you may be opening a large can of worms.

Good luck.

Edit: forgot to mention that you might want to bring up the liability aspect; if you are being told to knowingly bring someone to a hospital where they cannot get treatement...could make for a fun day in court no matter the final outcome.

 

[atropine]

Epi-do,
That is right. If I have a code STEMI, verified by 12-lead, they want me to bring this pt. to them even though they do not have the capabilities to do open heart or CATH. I can have this pt in an "appropriate" hospital in no more than 30 mins in most cases. If i am further than that then I can see coming to them first, but how much more time will be lost going there first and then transporting to the appropiate hospital! Long bone fractures are another problem. The ortho that covers the local hospital refuses to come in. He wants them in a soft cast until they can come into his office, so if the pt needs surgery, they have to be transported to a different hospital. Just seems like trying to do what's right for the pt is becoming more difficult because this hospital wants to get some of the money they are losing. I am not a newbie...I have over 15 years as a medic and can usually tell whats going to end up at a higher level of care. So my main question is not what I should do, but has anyone ran into legalities concerning this type of problem.[/QUO
Well if the MD is telling you what to do I say do it, besides any hospital is more appropriate than the back of an ambulance.

 

[JPINFV]

Well if the MD is telling you what to do I say do it, besides any hospital is more appropriate than the back of an ambulance.

Except... no... it's not. An ambulance is much more appropriate place for, say, a trauma patient compared to a non-trauma center provided that ambulance is transporting to a trauma center.

 

[Dwindlin]

Except... no... it's not. An ambulance is much more appropriate place for, say, a trauma patient compared to a non-trauma center provided that ambulance is transporting to a trauma center.

Depends on where you are. If you're an hour from the nearest trauma center then yeah, any hospital is much better than the back of an ambulance.

 

[redcrossemt]

Depends on where you are. If you're an hour from the nearest trauma center then yeah, any hospital is much better than the back of an ambulance.

Maybe... It depends on the hospital's capabilities and comfort level, your capabilities and comfort level, and the patient's needs.

I would argue that a hemodynamically stable trauma patient who needs specialty care should be driven directly to the trauma center if you have the capability to manage the patient's immediate and foreseen near-immediate problems during transport.

If you need an airway, chest tube, immediate control of hemorrhage, or (insert other life-threatening procedure here) and can't do it; then by all means go to the closest facility that can within reason.

 

[triemal04]

Depends on where you are. If you're an hour from the nearest trauma center then yeah, any hospital is much better than the back of an ambulance.

Honestly, even that would depend on a lot of factors.

What level of care can the hospital provide? Do they have access to surgeons? What type of surgeons? How long before they would be ready to operate? Do they have access to a CT scanner? How long till it's useable? What is their blood supply like? How is the ER staffed? Does it have a full-time ER doc and RN's, or just part-timers? How many are there? How long
will it take for the pt to be transferred out? Is there a quicker way to get them to the right hospital (helicopter)? Does the hospital have an ICU? A trauma team? 24/7 x-ray capability? It goes on for even more than that, believe me. For instance: http://www.oregon.gov/DHS/ph/ems/trauma/docs/exhibit4.pdf Look at what a level 4 community hospital is REQUIRED to have, and then ask yourself if you would feel comfortable bringing a major trauma there, especially if the only available transport was by ground.

I'll give Oregon credit; the trauma system is something they've done right; the only reason to divert to a lesser hospital is if the airway is unable to be secured, and then it's only until it's secure.

 

[amberdt03]

i'm sorry but patient care should definitely be any emt's or medic's top priority. if you take a confirmed stemi to a hospital without a functioning cath lab, then you're just wasting time for the patient not to mention adding unnecessary bills for 2 hospitals and 2 ambulance transports.

 

[Sasha]

JP, I have been told, even if you drive on to hospital grounds, find out you are on the wrong campus, and then drive off the grounds to the right one, you have broken EMTALA laws. A good example of this is would be the Boston Medical Center. You have the Boston City (Harrison Ave) and the BU campuses (East Newton). I was told that if they are going to the ER of one of the campuses, and you drive to the wrong one, and then drive to the right one, you have broken EMTALA. And, When talking about MedFlight, I would be calling for Medflight and the closest LZ is on hospital grounds, I would be calling CMED and letting the hospital know what was going on. Most ER doc's would still want to see the Pt even if it is for 2 minutes. Seen it done at the Jordan Hospital in Plymouth.

Saw it done here last month, the only people from the hospital that came out was hospital security to help secure the landing zone. (Although with the multiple fire engines and rescues and PDs that showed up to secure an already pretty secure location, the security really wasn't needed...)

And a direct admit comes on hospital campuses but bypass ER evals.

 

[JPINFV]

Saw it done here last month, the only people from the hospital that came out was hospital security to help secure the landing zone. (Although with the multiple fire engines and rescues and PDs that showed up to secure an already pretty secure location, the security really wasn't needed...)

And a direct admit comes on hospital campuses but bypass ER evals.

Au contraire. If the helicopter was flying into a proper helipad at the hospital, then the only people besides the medical crew transporting the patient that should have been there was hospital security. If anything goes wrong on their [the hospital's] pad, then the hospital will be at risk for a lawsuit. On the other hand, what's the fire engine and police going to do? Set up flares on the outskirts of a marked helipad? Does that fire department also respond when ever the local news helicopter takes off so that the news helicopter knows where to land at the heliport?

 

[Sasha]

Au contraire. If the helicopter was flying into a proper helipad at the hospital, then the only people besides the medical crew transporting the patient that should have been there was hospital security. If anything goes wrong on their [the hospital's] pad, then the hospital will be at risk for a lawsuit. On the other hand, what's the fire engine and police going to do? Set up flares on the outskirts of a marked helipad? Does that fire department also respond when ever the local news helicopter takes off so that the news helicopter knows where to land at the heliport?

We JUST had this conversation over AIM, dude... why post it?

 

[Dwindlin]

According to my medical director (as we had this question come up due to use of the hospital helipad on a scene response) EMTALA is only in effect if the patient or someone acting on the patients behalf requests to be seen by medical staff at that facility. Simply driving on to hospital property with a patient does not enact EMTALA.

Also, @triemal, yes I would bypass driving an hour with a major trauma patient and take them to the nearest facility. Even utilizing a helo you're looking at a 30 minute wait time, and the helo services in this area will NOT take an arrest. Plus not to mention its in violation of our protocol to divert to trauma center (even if the patient needs one) if it is greater than a 45 minute transport. Also in our protocol is NOT waiting on scene for a helo with a hemodynamically unstable patient.

If the patient is so unstable that a local ED couldn't even stablize them then there's even a higher likely hood the patient would have simply died sitting waiting for a helo, or on the hour drive to the trauma center.