The 21st Century Cures Act and Emergency Medicine - Part 1: Digitally Sharing Notes and Results.

Among the provisions of the 21st Century Cures Act is the mandate for digital sharing of clinician notes and test results through the patient portal of the clinician's electronic health record system. Although there is considerable evidence of the benefit to clinic patients from open notes and minimal apparent additional burden to primary care clinicians, emergency department (ED) note sharing has not been studied. With easier access to notes and results, ED patients may have an enhanced understanding of their visit, findings, and clinician's medical decisionmaking, which may improve adherence to recommendations. Patients may also seek clarifications and request edits to their notes. EDs can develop workflows to address patient concerns without placing new undue burden on clinicians, helping to realize the benefits of sharing notes and test results digitally.

Coding of Sexual Assault by Emergency Physicians: A Nationally Representative Study.

INTRODUCTION: Sexual assault is a public health problem that affects many Americans and has multiple long-lasting effects on victims. Medical evaluation after sexual assault frequently occurs in the emergency department, and documentation of the visit plays a significant role in decisions regarding prosecution and outcomes of legal cases against perpetrators. The American College of Emergency Physicians recommends coding such visits as sexual assault rather than adding modifiers such as "alleged." METHODS: This study reviews factors associated with coding of visits as sexual assault compared to suspected sexual assault using the 2016 Nationwide Emergency Department Sample. RESULTS: Younger age, female gender, a larger number of procedure codes, urban hospital location, and lack of concurrent alcohol use are associated with coding for confirmed sexual assault. CONCLUSION: Implications of this coding are discussed.

[Liaison geriatrics with nursing homes in COVID time. A new coordination model arrived to stay]. / La Geriatría de Enlace con residencias en la época de la COVID-19. Un nuevo modelo de coordinación que ha llegado para quedarse.

Older people living in nursing homes fulfil the criteria to be considered as geriatric patients, but they often do not have met their health care needs. Current deficits appeared as a result of COVID-19 pandemic. The need to improve the coordination between hospitals and nursing homes emerged, and in Madrid it materialized with the implantation of Liaison Geriatrics teams or units at public hospitals. The Sociedad Española de Geriatría y Gerontología has defined the role of the geriatricians in the COVID-19 pandemic and they have given guidelines about prevention, early detection, isolation and sectorization, training, care homes classification, patient referral coordination, and the role of the different care settings, among others. These units and teams also must undertake other care activities that have a shortfall currently, like nursing homes-hospital coordination, geriatricians visits to the homes, telemedicine sessions, geriatric assessment in emergency rooms, and primary care and public health services coordination. This paper describes the concept of Liaison Geriatrics and its implementation at the Autonomous Community of Madrid hospitals as a result of COVID-19 pandemic. Activity data from a unit at a hospital with a huge number of nursing homes in its catchment area are reported. The objective is to understand the need of this activity in order to avoid the current fragmentation of care between hospitals and nursing homes. This activity should be consolidated in the future.

Vascular surgery-related violations of the Emergency Medical Treatment and Labor Act.

OBJECTIVE: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law established in 1986 to ensure that patients who present to an emergency department receive medical care regardless of means. Violations are reported to the Centers for Medicare and Medicaid Services and can result in significant financial penalties. Our objective was to assess all available EMTALA violations for vascular-related issues. METHODS: EMTALA violations in the Centers for Medicare and Medicaid Services publicly available hospital violations database from 2011 to 2018 were evaluated for vascular-related issues. Details recorded were case type, hospital type, hospital region, reasons for violation, disposition, and mortality. RESULTS: There were 7001 patients identified with any EMTALA violation and 98 (1.4%) were deemed vascular related. The majority (82.7%) of EMTALA violations occurred at urban/suburban hospitals. Based on the Association of American Medical Colleges United States region, vascular-related EMTALA violations occurred in the Northeast (7.1%), Southern (56.1%), Central (18.4%), and Western (18.4%) United States. Case types included cerebrovascular (28.6%), aortic related (22.4%; which consisted of ruptured aortic aneurysms [8.2%], aortic dissection [11.2%], and other aortic [3.1%]), vascular trauma (15.3%), venous-thromboembolic (15.3%), peripheral arterial disease (9.2%), dialysis access (5.1%), bowel ischemia (3.1%), and other (1%) cases. Patients were transferred to another facility in 41.8% of cases. The most common reasons for violation were specialty refusal or unavailability (30.6%), inappropriate documentation (29.6%), misdiagnosis (18.4%), poor communication (17.3%), inappropriate triage (13.3%), failure to obtain diagnostic laboratory tests or imaging (12.2%), and ancillary or nursing staff issues (7.1%). The overall mortality was 19.4% and 31.6% died during the index emergency department visit. Vascular conditions associated with death were venous thromboembolism (31.6%), ruptured aortic aneurysm (21.1%), aortic dissection (21.1%), other aortic causes (10.5%), vascular trauma (10.5%), and bowel ischemia (5.3%). CONCLUSIONS: Although the frequency of vascular-related EMTALA violations was low, improvements in communication, awareness of vascular disease among staff, specialty staffing, and the development of referral networks and processes are needed to ensure that patients receive adequate care and that institutions are not placed at undue risk.

Regulatory Challenges to Emergency Medicine Procedural Sedation.

As currently written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date. As a result, hospital procedural sedation policies are often widely inconsistent between institutions despite similar settings and resources, putting emergency department (ED) patients at risk by denying them uniform access to safe, effective, and appropriate procedural sedation care. Many hospitals have chosen to take overly conservative stances with respect to regulatory compliance to minimize their perceived risk. Herein, we review and critique standards and policies from the Centers for Medicare & Medicaid Services, The Joint Commission, state nursing boards, the Food and Drug Administration, and others with respect to their effect on ED procedural sedation. Where appropriate, we recommend modifications of and enhancements to their guidance that would improve the access of ED patients to modern, safe, and effective procedural sedation care.

Problemas de información a los padres y tutores en la asistencia a urgencias en menores de 14 a 17 años por consumo de sustancias psicoactivas / Issues with information given to parents and guardians on medical care in the emergency department relating to minors aged from 14 to 17 years due to psychoactive substance

INTRODUCCIÓN: El cumplimiento de los deberes de la patria potestad exige a los padres y/o tutores estar informados de aquellos aspectos relevantes relacionados con la salud del menor. La legislación actual reconoce la autonomía a partir de los 16 años o menores emancipados. En este trabajo se analiza la información que reciben los padres o tutores legales de los menores mayores de 14 años que acuden a un servicio de urgencias hospitalario general de tercer nivel por intoxicación aguda por alcohol y otras drogas de abuso incluidos medicamentos como las benzodiacepinas si se consumen con fines recreativos. MATERIAL Y MÉTODOS: Se revisaron las historias clínicas de los menores atendidos en el servicio de urgencias de un hospital de tercer nivel durante los años 2016 y 2017 para conocer la información referida a los padres y se entrevistó a los médicos y enfermeros de dicho servicio para conocer la información que daban a los padres/tutores. RESULTADOS: En las historias clínicas en las que se citaba que el menor iba acompañado por amigos (11,5%), 5 de ellas (9,6%) no especificaban si se había realizado el aviso a padres/tutores. De las 26 historias clínicas (50%) en las que no había especificación del acompañamiento, en 22 (42,3%) tampoco existía especificación del aviso. Mientras que 28 de los 35 encuestados (80%) afirma avisar siempre que el menor no hubiera ido acompañado por sus padres o tutores. CONCLUSIONES: Se pone de manifiesto la existencia de una falta de información de tipo asistencial relativa al aviso a padres/tutores, así como una discrepancia entre los datos proporcionados por los médicos y enfermeros y los obtenidos en las historias clínicas

BACKGROUND: In accordance with parental legal duties, parents and guardians should be informed about health issues relevant to child health. Current Spanish legislation acknowledges autonomy from 16 years or emancipated minors. This study analyses the information given to the parents or legal guardians of minors over 14 years of age attending a tertiary-level general hospital emergency department on psychoactive substance intoxication (alcohol, cannabis, benzodiazepines). MATERIAL AND METHODS: The medical records of minors treated in the emergency department of a tertiary-level hospital, between 2016 and 2017, were reviewed. A survey of medical and nursing professionals from the emergency services was also conducted. RESULTS: Of the medical records that mentioned that the minor attended the emergency department with friends (11.5%), 5 (9.6%) did not specify if the parents or guardians were called. Of the 26 medical records (50%) in which there was no mention of whether if the minor attended alone or accompanied, 22 (42.3%) made no mention of informing parents. The study data show that 28 of the 35 respondents (80%) always notified if the minor had not been accompanied to the emergency department by a parent or guardian. CONCLUSIONS: There is lack of information relating to informing parents/guardians, as well as a discrepancy between the data provided by health professionals and the medical reports analysed

EMTALA: Testing the Good Faith Admission Requirement.

The Fourth Circuit Court of Appeals' March 13, 2020 decision in Williams v. Dimension Health Corporation reintroduced scrutiny on the lesser-known mandate of The Emergency Medical Treatment and Active Labor Act (EMTALA) concerning good faith admission to the hospital. EMTALA was enacted by Congress in 1986 to prevent patient dumping by prohibiting hospitals with emergency departments from refusing to provide emergency medical treatment to patients unable to pay for treatment, and prohibiting the transfer of those patients before their emergency medical conditions are stabilized. The reach of EMTALA ends when a patient is admitted and consequently becomes an inpatient, because then the hospital believes the patient would benefit from admission, and discharge and transfer would not occur as outlined in EMTALA. This paper examines the analysis of this mandate in Williams v. Dimension Health Corporation, and closely investigates one particular aspect of it: that admission must be made in good faith; otherwise, application of EMTALA's screening and stabilization requirements has not yet terminated, and hospitals can still be found culpable.

The Association Between Hospital Characteristics and Emergency Medical Treatment and Labor Act Citation Events.

OBJECTIVES: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law enacted in 1986 prohibiting patient dumping (refusing or transferring patients with emergency medical conditions without appropriate stabilization), and discrimination based upon ability to pay. We evaluate hospital-level features associated with citation for EMTALA violation. MATERIALS AND METHODS: A retrospective analysis of observational data on EMTALA enforcement (2005-2013). Regression analysis evaluates the association between facility-level features and odds of EMTALA citation by hospital-year. RESULTS: Among 4916 EMTALA-obligated hospitals there were 1925 EMTALA citation events at 1413 facilities between 2005 and 2013, with 4.3% of hospitals cited per year. In adjusted analyses, increased odds of EMTALA citations were found at hospitals that were: for-profit [odds ratio (OR): 1.61; 95% confidence interval (CI): 1.32-1.96], in metropolitan areas (OR: 1.32; 95% CI: 1.11-1.57); that admitted a higher proportion of Medicaid patients (OR: 1.01; 95% CI: 1.0-1.01); and were in the top quartiles of hospital size (OR: 1.48; 95% CI: 1.10-1.99) and emergency department (ED) volume (OR: 1.56; 95% CI: 1.14-2.12). Predicted probability of repeat EMTALA citation in the year following initial citation was 17% among for-profit and 11% among other hospital types. Among citation events for patients presenting to the same hospital's ED, there were 1.30 EMTALA citation events per million ED visits, with 1.04 at private not-for-profit, 1.47 at government-owned, and 2.46 at for-profit hospitals. CONCLUSIONS: For-profit ownership is associated with increased odds of EMTALA citations after adjusting for other characteristics. Efforts to improve EMTALA might be considered to protect access to emergency care for vulnerable populations, particularly at large, urban, for-profit hospitals admitting high proportions of Medicaid patients.

Learning the developments in EMTALA jurisprudence through the lens of John West's "case law update".

This article covers three recurring issues concerning the federal law known as the Emergency Medical Treatment and Labor Act (EMTALA) that keep popping up in John West's Case Law Update case updates, and consistently bedevil hospital risk managers. First, what exactly constitutes an "appropriate" medical screening examination; second, when is a patient actually "stabilized' under EMTALA; and third, does the EMTALA obligation really "disappear" when a patient is admitted to the hospital? The editors wanted to analyze topics that challenge the courts to "get it right" on the law and that drive risk managers crazy. EMTALA is the "poster child" for such a topic.

Take-Home Naloxone Program Implementation: Lessons Learned From Seven Chicago-Area Hospitals.

Despite consensus recommendations from the American College of Emergency Physicians (ACEP), the Centers for Disease Control and Prevention, and the surgeon general to dispense naloxone to discharged ED patients at risk for opioid overdose, there remain numerous logistic, financial, and administrative barriers to implementing "take-home naloxone" programs at individual hospitals. This article describes the recent collective experience of 7 Chicago-area hospitals in implementing take-home naloxone programs. We highlight key barriers, such as hesitancy from hospital administrators, lack of familiarity with relevant rules and regulations in regard to medication dispensing, and inability to secure a supply of naloxone for dispensing. We also highlight common facilitators of success, such as early identification of a "C-suite" champion and the formation of a multidisciplinary team of program leaders. Finally, we provide recommendations that will assist emergency departments planning to implement their own take-home naloxone programs and will inform policymakers of specific needs that may facilitate dissemination of naloxone to the public.

Penalties for Emergency Medical Treatment and Labor Act Violations Involving Obstetrical Emergencies.

INTRODUCTION: The Emergency Medical Treatment and Labor Act (EMTALA) was intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (ED). While controversies exist regarding the scope of the law, there is no question that EMTALA applies to active labor, a key tenet of the statute and the only medical condition - labor - specifically included in the title of the law. In light of rising maternal mortality rates in the United States, further exploration into the state of emergency obstetrical (OB) care is warranted. Understanding civil monetary penalty settlements levied by the Office of the Inspector General (OIG) related to EMTALA violations involving labor and other OB emergencies will help to inform the current state of access to and quality of OB emergency care. METHODS: We reviewed descriptions of all EMTALA-related OIG civil monetary penalty settlements from 2002-2018. OB-related cases were identified using keywords in settlement descriptions. We described characteristics of settlements including the nature of the allegation and compared them with non-OB settlements. RESULTS: Of 232 EMTALA-related OIG settlements during the study period, 39 (17%) involved active labor and other OB emergencies. Between 2002 and 2018 the proportion of settlements involving OB emergencies increased from 17% to 40%. Seven (18%) of these settlements involved a pregnant minor. Most OB cases involved failure to provide screening exam (82%) and/or stabilizing treatment (51%). Failure to arrange appropriate transfer was more common for OB (36%) compared with non-OB settlements (21%) (p = 0.041). Fifteen (38%) involved a provider specifically directing a pregnant woman to proceed to another hospital, typically by private vehicle. CONCLUSION: Despite inclusion of the term "labor" in the law's title, one in six settlements related to EMTALA violations involved OB emergencies. One in five settlements involved a pregnant minor, indicating that providers may benefit from education regarding obligations to evaluate and stabilize minors absent parental consent. Failure to arrange appropriate transfer was more common among OB settlements. Findings suggesting need for providers to understand EMTALA-specific requirements for appropriate transfer and for EDs at hospitals without dedicated OB services to implement policies for evaluation of active labor and protocols for transfer when indicated.

Emergency Radiology: An Underappreciated Source of Liability Risk.

PURPOSE: While several studies analyze radiology malpractice lawsuits, none specifically examines the site of service. The purpose of this study is to estimate the relative likelihood of a lawsuit arising from a radiology study performed in emergency (ED), inpatient (IP) and outpatient (OP) settings. METHODS: Referrals from a malpractice review consulting company over a six year period were compared to the 2016 Medicare Part B file and stratified by site of service. The proportion of exams for each site of service was estimated, and using absolute differences in proportions and odds ratios (ORs), differences in the place of service were calculated. RESULTS: The Cleareview cohort contained 25 (17%) IP, 56 (38%) OP, and 68 (46%) ED exams. In 2016, Medicare assigned benefits for 27,009,053 (20%) IP, 84,075,848 (62%) OP and 23,964,794 (18%) ED exams. The ORs (Cleareview: Medicare) of the ED to IP, OP, and IP+OP were 3.07 (95% CI: 1.56-6.03), 4.26 (95% CI: 2.76-6.59), 3.89 (95% CI: 2.60-5.83), respectively. By contrast, the OR for IP:OP between Cleareview and Medicare was not significantly different than 1 (OR: 1.39, 95% CI: 0.68-2.83, P = .38). DISCUSSION: Radiological studies performed in the ED accounted for a disproportionate number of liability claims against radiologists. Further study is warranted to confirm this finding with a more robust data set.

Physician Documentation of Access to Firearms in Suicidal Patients in the Emergency Department.

INTRODUCTION: Suicide is the 10th leading cause of death in the United States. An estimated 50% of these deaths are due to firearms. Suicidal ideation (SI) is a common complaint presenting to the emergency department (ED). Despite these facts, provider documentation on access to lethal means is lacking. Our primary aim was to quantify documentation of access to firearms in patients presenting to the ED with a chief complaint of SI. METHODS: This was a cross-sectional study of consecutive patients, nearly all of whom presented to an academic, urban ED with SI during July 2014. We collected data from all provider documentation in the electronic health record. Primary outcome assessed was whether the emergency physician (EP) team documented access to firearms. Secondary outcomes included demographic information, preexisting psychiatric diagnoses, and disposition. RESULTS: We reviewed 100 patient charts. The median age of patients was 38 years. The majority of patients had a psychiatric condition. EPs documented access to firearms in only 3% of patient charts. CONCLUSION: EPs do not adequately document access to firearms in patients with SI. There is a clear need for educational initiatives regarding risk-factor assessment and counseling against lethal means in this patient cohort.

Audiovisual recording in the emergency department: Ethical and legal issues.

Emergency physicians, organizations and healthcare institutions should recognize the value to clinicians and patients of HIPAA-compliant audiovisual recording in emergency departments (ED). They should promote consistent specialty-wide policies that emphasize protecting patient privacy, particularly in patient-care areas, where patients and staff have a reasonable expectation of privacy and should generally not be recorded without their prospective consent. While recordings can help patients understand and recall vital parts of their ED experience and discharge instructions, using always-on recording devices should be regulated and restricted to areas in which patient care is not occurring. Healthcare institutions should provide HIPAA-compliant methods to securely store and transmit healthcare-sensitive recordings and establish protocols. Protocols should include both consent procedures their staff can use to record and publish (print or electronic) audiovisual images and appropriate disciplinary measures for staff that violate them. EDs and institutions should publicly post their rules governing ED recordings, including a ban on all surreptitious or unconsented recordings. However, local institutions may lack the ability to enforce these rules without multi-party consent statutes in those states (the majority) where it doesn't exist. Clinicians imaging patients in international settings should be guided by the same ethical norms as they are at their home institution.