Three Mass. ERs cited for denial of care

[Esme12, ASN, BSN, RN]

I commented on a thread earlier today about Emergency Departmetn Diversions and the hospitals obligation to treat. In MA diversion status no longer exists but is where stressed systems are heading?

Changes made; one patient died By Liz Kowalczyk Globe Staff April 23, 2012

"Health officials cited three Massachusetts hospitals in the past six months for wrongly sending away patients from their emergency rooms, in one case resulting in the death of a patient while en route to another facility.

In that episode, caregivers at Charlton Memorial Hospital in Fall River failed to provide needed medical treatment before transferring the patient, who was unstable and in respiratory distress, state investigators concluded.

In a case at St. Vincent Hospital in Worcester, an on-call surgeon refused to come in late at night to perform an emergency operation on a patient with flesh-eating bacteria, investigators found. The patient was transferred to another hospital, and the surgeon no longer operates on patients at St. Vincent, hospital officials said.

Hospitals that break federal rules ensuring public access to emergency services can face especially tough sanctions. Flagrant or repeat violators risk losing their right to treat Medicare and Medicaid patients, which can cost a hospital millions of dollars.

Charlton, St. Vincent, and Lahey Clinic in Burlington - which turned away an emergency room patient in November - have been told they will not lose their Medicare contracts, but they could be fined. Federal officials said it is unusual to have three cases in such a short span.

Even though emergency rooms are growing more congested with patients, investigators said they did not find evidence that crowding was a factor in the three cases, which they do not believe are connected. But they said they are on alert for underlying pressures that might be contributing to patient care problems.

"We are watching it very closely,'' said Dr. Madeleine Biondolillo, director of the state's Bureau of Health Care Safety and Quality, in an interview.

The law guaranteeing access to emergency care originally was intended to prevent hospitals from turning away uninsured patients who cannot pay for treatment. The law requires hospitals to provide patients with a "medical screening exam'' and to treat and stabilize patients with emergency medical conditions. Medicare officials said that there were 11 violations of the rules in New England last year, 13 in 2010, and seven in 2009.

Executives at Lahey and St. Vincent said lack of insurance was not a factor in the cases at their hospitals. Executives at Charlton, part of Southcoast Hospitals Group, would not answer questions about the case in which the patient died.

The Charlton patient was coughing and short of breath upon arriving in the emergency room at 7:30 p.m. Aug. 9. Over the next few hours, the patient, who had been diagnosed with a serious lung disease as a child, required oxygen. The patient had received care at a teaching hospital in the past and wanted to be transferred there. At 9:45 p.m., an emergency room doctor decided the patient was stable enough for a trip to the other hospital.

After another doctor came on duty about 10:30 p.m., the patient deteriorated. In citing the hospital in February, health officials said the second doctor failed to recognize that the patient was unstable and perhaps too sick to be moved - even though the ambulance crew expressed concerns - and that caregivers did not insert a breathing tube in case mechanical ventilation was needed on the ride.

"We continually strive to improve the access, quality, and effectiveness of our services and are dedicated to delivering the safest, highest quality care to all of our patients,'' Charlton spokeswoman Stephanie Lynn Poyant said in a written statement. "We investigated the case carefully and made corrective actions that when surveyed by the Department of Public Health were found to have been effective over the longer term.''

According to state documents, Charlton mandated that doctors and nurses reassess all patients before transfer, and that they exchange more information about patients during shift changes.

In the St. Vincent case, a patient arrived in the emergency room on Oct. 16 shortly before 8:30 p.m. with a fever and pain from an abscess on the right buttock. The physician who evaluated the patient told investigators the patient "was in poor shape'' and needed emergency surgery in order to remove the dead tissue and improve chances of survival.

But state investigators said the hospital failed to ensure a surgeon was available. The surgeon on call would not come in that night and had "various reasons'' for wanting to wait until 6 a.m., according to the state report dated Jan. 4. The surgeon told investigators "it was better for him to come to the hospital in the morning.''

The emergency room doctor transferred the patient to UMass Memorial Medical Center, a competitor, because he did not want the patient to lose more time waiting for surgery. A UMass spokesman said he could not disclose the fate of the patient because of privacy rules.

Dr. Octavio Diaz, St. Vincent chief medical officer, said the surgeon, who was employed by a nearby medical group, "is no longer on the call schedule and no longer seeing patients here.''

"It's completely unacceptable to us,'' he said. "The minutes do count. Antibiotics can slow this infection, but it's an operation the patient needs. The ER did a terrific job recognizing this.''

In the Lahey case, caregivers told a patient who arrived at the hospital in Peabody on Nov. 19 that he was banned from the emergency room there and from the hospital's emergency room in Burlington. He was not evaluated or treated, and was "escorted off the grounds in a wheelchair by a security guard,'' according to state investigators.

Sullivan, Lahey's chief quality officer, citing privacy rules, would not say why caregivers attempted to ban the patient. She said he went to another hospital, which called Lahey several hours later and questioned why he wasn't treated there. Lahey staff apologized and an ambulance brought him to the Burlington hospital, where he was admitted.

A nurse and a doctor involved in the case were put on unpaid leave for 30 days and retrained in the emergency care law, and all emergency room doctors and nurses will undergo yearly education on the regulations.

"This is a message to all of us that there are certain things we have to do and we have to get them right,'' she said.

http://www.bostonglobe.com/metro/2012/04/22/massachusetts-cites-hospitals-for-inappropriate-care-patients-emergency-rooms/ZnPvfzesk1AufoXXi2bzGN/story.html

[netglow, ASN, RN]

ER docs worry often about being left twisting in the wind by surgeons...

[ckh23, BSN, RN]

A surgeon didn't want to come in in the middle of the night. Shocking.

[BostonTerrierLover, BSN, RN]

Oh, The awesome responsibility you take when you clock-in. Even on diversion, we have had to reprioritize, but this is extremely unsettling. This is about a death, Can you imagine how many "close" calls, and negative outcomes have occured. We need help from our legislators for more protection vs. reforms in the Emergency Room P&P to prevent this kind of thing.

I never forget when I slide that badge that we are on the "Front-Lines," and that one un-noticed mistake could be my last in practice. Of all the advice I have given on Allnurses.com, and read, truly vital tests and challenges WILL come. All I can say, if your gut knows what right, and right isn't being done- you have to speak-up, you have to follow-up every Challenge/Trial until it is resolved, or it will come back to bite you.

Short Cuts equal sleep deprivation, and negative patient outcomes. This is truly sad, and I am sad to say, the answer may be hidden in the "Gray" areas. All I know, you are a wide-open target in the Emergency Department, and Alertness, Intuition, and thorough documentation are a MUST, along with the electives of being clever, reading between the lines, and covering your rump every minute. This is scary on SO many levels. CYA CYA CYA!!!!! All I can think about is HOW OVERWHELMED we were when we actually WERE in diversion, and how there were sometimes even "Reprioritizing" would be like "Field Tagging/Triage." Gray Areas cause a world of damage, confusion, and loss- but are a fact of life, and the complexities in P&P/Legality of the Emergency Department! God Help Us!

Good Luck Fellow ED/ER Nurses.

:redbeatheBoston

[Esme12, ASN, BSN, RN]

Massachusetts no longer allows diversion unless an internal disaster/quarantine. This stuff goes on every day. These hospitals are spread over a large demographic and square miles. Two of them are affiliated but far apart. Are theses symptoms of a broken and terminally ill system?

[GitanoRN, BSN, MSN, RN]

i'm a firm believer that hospital diversion protocol should be re-evaluated in all states in order to prevent any human loss. as we all know when a hospital goes on diversion, it notifies area emergency medical services ems units so that they can consider transporting patients to other hospitals that are not on diversion. having said that, patients still have the right to request transportation to the hospital of their choice. however, going to a hospital on diversion means that the patient may have a lengthy wait before receiving treatment, this does not give the hospital the right to refuse any pt.

a hospital on diversion is not closed nor its emergency room, hospitals should always accept patients who arrive on their own, or who are brought by family or friends to ed. furthermore, hospitals always accept unstable patients who are brought by ambulances diversion or not, this was an unfortunate incident and i hope and pray that we all have learned from it. my thoughts and prayers are with the family and friends of those who's life's were lost because of hospital diversion.

[Esme12, ASN, BSN, RN]

i'm a firm believer that hospital diversion protocol should be re-evaluated in all states in order to prevent any human loss. as we all know when a hospital goes on diversion, it notifies area emergency medical services ems units so that they can consider transporting patients to other hospitals that are not on diversion. having said that, patients still have the right to request transportation to the hospital of their choice. however, going to a hospital on diversion means that the patient may have a lengthy wait before receiving treatment, this does not give the hospital the right to refuse any pt.

a hospital on diversion is not closed nor its emergency room, hospitals should always accept patients who arrive on their own, or who are brought by family or friends to ed. furthermore, hospitals always accept unstable patients who are brought by ambulances diversion or not, this was an unfortunate incident and i hope and pray that we all have learned from it. my thoughts and prayers are with the family and friends of those who's life's were lost because of hospital diversion.

this was 3 incidents in 6 months....2 by the same facility different sites. my question is this a symptom of an ever increasing problem that will get worse as cuts, reimbursements get worse?

[martymoose, BSN, RN]

well, if so many crackheads and drug addicts weren't using the ED as their drug supplier, maybe things wouldnt have come to this.

[GitanoRN, BSN, MSN, RN]

this was 3 incidents in 6 months....2 by the same facility different sites. my question is this a symptom of an ever increasing problem that will get worse as cuts, reimbursements get worse?

esme12, i'm afraid you just answered your own question...having said that, the other parties involved would be administration & politics, which i'm sure it comes to no surprise to some of us i'm sad to say.

[Esme12, ASN, BSN, RN]

I know I did......I have worked in the ED system a lifetime. I was around when the EMTALA/COBRA laws were enacted and I know why they had to be enacted.

I am frightened to where this will all end.

There is a feces strom a brewing.....

[NO50FRANNY]

It is interesting that for such a vastly different health care system (US Vs OZ) the similarities are uncanny. At the moment, the powers that be in my city are trying to bring in legislation that stops any public (free) hospital going on re-direct. I personally believe this will never happen and I work in the hospital who essentially isn't allowed to close. The rules at present state that even when on re-direct, hospitals are obliged to accept walk ins or ctitically ill patients. Unfortunately, ambulance crews are still turned away regardless of pt. acuity. There is a long entrenched culture of obstruction from many of the hospitals (sadly, largely from nursing staff) in my city, to the point that many crews don't even attempt taking their sick pts to other facilities. I appreciate working at the tertiary / trauma referral centre and like that we never close our doors but I do not understand how truly sick people can be turned away. This story is a matter of public record. A couple of years ago, a gentleman had open heart surgery at the hospital nearest ours whose specialty is cardiothoracics and a few days post discharge he developed acute SOB, haemoptysis and felt terrible. His wife called his treating hospital and listed his symptoms for the triage nurse, which unfortuantely included 1 dark stool early that morning. The triage nurse told her that she would need to take him to our facility (10 mins further) instead as they didn't have a gastro department and the dark stool could have been a GI bleed. His wife argued that this was not his primary concern, she explained that he had only recently had major heart surgery and the breathing and coughing were his primary complaint. The triage nurse told her NO, she would have to bring him to us.

A little note about us, but it's a whole different thread- we don't have a coronary bypass machine. By the time he was assessed in our ED, in obvious APO then deteriorated into cardiogenic shock and was transferred back to his primary treating hospital nearly 8 hours after this phone call, they couldn't get him off bypass and he died. The coroners report was sad to read. This was not a question of incompetence, but a culture of refusal. This same hospital, while on re-direct tried to refuse a patient with chest pain, the ambulance crew ignored the nurse at the front doors who yelled "WE ARE ON BYPASS!" and charged into the resuscitation area with their pt. who had a VF arrest 10 minutes later. I know how appalling our department is when we go on bypass (maybe twice in two years) but we still accept very sick people, we just make do. Our ED is penalised financially to the tune of $15000 in funding for every hour we are on bypass, unfortunately these penalties to not apply to the other facilities. It is truly a political minefield but the patients are the ones who dip out and it's happening more and more often. I just have a hard time with "Oh, you are about to die, well that's too bad because we are far too busy, just continue on down the road for your last 10 minutes". How can anyone do that? But I digress, underesourced, overrun and understaffed, that's where this culture starts.