Did She Violate Patient Confidentiality?

[0121Mednurse]

This incident happened recently, and I would like to know what you all think.

It is unknown why this gentleman was in the ER at a Texas hospital other than he drove himself there one afternoon. One of the tests ordered was a BAC level. By the way, according to the ER nurse, he smelled of an unknown alcoholic beverage. A little over an hour had passed, and he decided to leave. The ER Nurse tries to convince him to stay, but he tells her that his fiancé will be meeting him in the parking lot. The Nurse follows him, and she sees him getting into the driver’s seat of his pickup. There happened to be a Sheriff’s Deputy in full uniform that was working extra as hospital security that day in the ER. The Nurse tells the Deputy that she believes the gentleman is intoxicated. The Deputy asked the Nurse what led her to believe he was drunk. The Nurse said, “he has a strong odor of an unknown alcoholic beverage, and his BAC is .367.

Do you think the Nurse breached patient confidentiality? I think it’s safe to assume the Nurse was trying to keep the patient and the community safe; however, how many of us believe she didn’t need to disclose his BAC level?

[klone, MSN, RN]

Is this a homework assignment?

[Hoosier_RN, MSN]

At the local hospitals in my area, they give this info, if known, to LEOs and other healthcare providers, as it is pertinent to the pursuit and further care. He did ask, and it was an acceptable response. She didn't provide non-pertinent info

[JKL33]

5 hours ago, 0121Mednurse said:

Do you think the Nurse breached patient confidentiality? I think it’s safe to assume the Nurse was trying to keep the patient and the community safe; however, how many of us believe she didn’t need to disclose his BAC level?

What do you think?

 

[Nursemateo, RN, EMT-B]

I'm inclined to agree with @klone this reads like a. copy and paste of an assignment. If it is I hope you will formulate your own opinion. 

However, as an ED nurse I have been faced with this exact case on more than one occasion, the answer is not as black and white as you would assume. I would encourage you to review the attached comment from the University of Dayton Law Review from 2016 I feel it is a comprehensive analysis of the different factors at play in the scenario. 

In practice if an intoxicated person is attempting to leave the ED the providers I work with will place the patient on an involuntary hold which I legally enforceable by law enforcement without disclosure of PHI. 

 

Raines, Rebeccah Therkelson (2016) "Evaluating the Inebriated: An Analysis of the HIPAA Privacy Rule and Its Implications for Intoxicated Patients in Hospital Emergency Departments," University of Dayton Law Review: Vol. 40: No. 3, Article 8. 
Available at: https://ecommons.udayton.edu/udlr/vol40/iss3/8

[0121Mednurse]

 @Nursemateo I thought this forum was so nurses could interact with fellow nurses and get opinions on subject matters. I was curious to see everyone's point of view on the matter. If I were a student then your attachment would be helpful but I am not.

@klone thank you for asking if I was a student instead of accusing me of being one.

@JKL33 I think notifying the Deputy of an intoxicated individual based on the fact that the patient smelled of a strong unknown alcoholic beverage is sufficient information that would not have put her in a position where she could be facing a violation. Why in my opinion? If the Deputy felt that the information given about smelling alcohol on the patient was not sufficient enough for him to stop this guy in the parking lot,  then that's on law enforcement.  This gentleman drunk or not was a patient and she could protect both the public and her patient without giving out private information.

 

[klone, MSN, RN]

I would say that what the patient smells like is irrelevant if the nurse has the BAC result. Go by facts, not subjective observations.

[Nursemateo, RN, EMT-B]

As a practicing nurse I still review literature on a regular basis when faced with intricate questions of duty, law, and ethics.  I found the article very helpful there are a lot of different factors at play legally that I had not thought of when I first dealt with this in person. Of course this forum is for discussion of opinions of other nurses and I see I didn’t really give mine. 
Personally if I do not have a legal avenue to inform law enforcement then he would walk, I will not risk disclosing PHI. I have on more than one occasion refused to give that information until I have a warrant, which they always manage to get pretty quickly.

[JKL33]

13 hours ago, Nursemateo said:

Personally if I do not have a legal avenue to inform law enforcement then he would walk, I will not risk disclosing PHI. I have on more than one occasion refused to give that information until I have a warrant, which they always manage to get pretty quickly.

Agree. I think in this scenario there is a legal avenue.

However, when officers are just standing around in the ED or even the nurse's station asking questions about someone they've brought in, that is a huge no for me. They can get a warrant. I almost single-handedly changed the culture in one ED because I was very open and pleasantly up-front about telling them that for all our sakes and that of the patient they need to get all info through proper channels; enough of my coworkers heard these convos (along with my rationale) that they changed their practice. I will not give them verbal info or let them view PHI about patient's they've brought in for their own law enforcement reasons. The OP scenario is different; in that case it is the healthcare professional that is initiating an allowable disclosure of PHI through a legally defensible avenue.

The article you posted was well-written. Personally I have always felt HIPAA was pretty clear on this matter. IME it's usually hospital admins that cause confusion with their sweeping directives, overgeneralizations and business-related motivations.

On 10/9/2022 at 11:15 PM, 0121Mednurse said:

If the Deputy felt that the information given about smelling alcohol on the patient was not sufficient enough for him to stop this guy in the parking lot,  then that's on law enforcement.  This gentleman drunk or not was a patient and she could protect both the public and her patient without giving out private information.

I understand your rationale but at the same time that approach is a bit misleading; you're asking the officer to pretend to have his/her own suspicion based on your "trust me bro" info, when you could provide a much more solid reason that you believe the patient is indeed intoxicated. If the objective is really to protect the patient and the public (which is the legally defensible reason for a disclosure here), then the disclosure should include sufficient information to facilitate the action that would more readily/reliably provide protection.

[SFANRN3421]

I would say that this is dependent on: Hospital/ER/or Facility Policy in addition to the state laws in place and the state's NPA. 

I think it is certainly an ethical issue and an interesting question. 

I tend to think that this information could have been communicated with the officer without including the details of the BAC.                                       

As it is often said, the devil is always in the details.  How much time had passed between the lab draw and when the nurse received and reviewed the results? Was the patient receiving IV fluids or hydration during that period of time?  Age, medical history, body weight or size could all potentially be relevant factors in this equation as well.   

I can only assume the nurse remained concerned over this based on other observations and factors beyond the lab results. 

An even better question may be: Could the nurse be held liable for what happened after he left?  I would say probably not due to the fact that he told her that he had someone picking him up, but I would venture to say that the laws likely vary from one state to the next on this.  

[SFANRN3421]

You also have an obligation to the patient and to protect the patient's protected healthcare related information.  Let's not forget that labs can actually be wrong and inaccurately calibrated and equipment sometimes malfunctions.  I would say you have to go back to the state BNE or review the NPA in your state to see what you are actually "obligated" to do in a situation of this type.  I would also consider the hospital policy, which I assume is congruent with the states stance on everything.  

You also don't know the relationship that the off duty officer has with this nurse. Maybe the reaction the officer had is a result of some other experience with this nurse or some other reason. 

There is not enough information in this scenario for me to make a decision.  Assuming I wasn't a supervisor, I would have likely addressed it with my supervisor and let them handle it.  

There are too many other factors to consider.  

I do think this is a great question and one that makes you stop and think. 

[Norubit15, ASN, BSN, CNA, LPN, RN]

Yes, I feel that PHI has been violated.  The patient did not give consent.  I understand the nurse was concerned for the patient and the community, however she could have just stated that she suspected the patient of drinking alcohol.