Diastolic Dysfunction: Not So Benign

The original models of chronic heart failure (CHF) simplistically viewed the problem as 'inadequate pumping,' manifest as a decreased ejection fraction. With wider availability of ECHO-cardiography it became clear that many patients with prototypic signs and symptoms CHF had normal ejection fractions. Soon it became evident that poor filling (diastolic dysfunction) can result in clinical syndromes which are indistinguishable from poor contractile function (systolic dysfunction). An EF (ejection fraction) < 40% is consistent with systolic dysfunction.

Mortality from the time of diagnosis of CHF is substantial, surpassing the mortality rates of many of the most common cancers in America, prompting some to label CHF the 'hemodynamic malignancy.' Some data have suggested that diastolic dysfunction (DDF) has a more benign prognosis than systolic dysfunction (SDF).

Over a two-year period, CHF patients hospitalized in Ontario, Canada (n = 2,802) for whom data on ejection fraction were available, were followed for the outcomes of mortality within one year and hospital readmission (for CHF). Outcomes for persons with SDF and DDF were compared. Both the mortality at 1 year (22% vs 26%; P = NS) and the rate of CHF readmission were similar between the two groups. Although past data have suggested a more benign outcome for DDF than SDF, this robust study indicates similar outcomes for either mechanism of heart failure.

Source: Bhatia RS, et al. N Engl J Med. 2006;355:260-269.

From: Clinical Briefs In Primary Care

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Applying EMTALA To Behavioral Emergencies

Question: The police present at a busy ED seeking medical clearance for an individual they are holding with a suspected behavioral emergency. The hospital does not offer psychiatric services. The police do not want to wait around for several hours for medical clearance, so they leave the hospital (which is not authorized to hold the patient involuntarily). The emergency physician confirms that the patient is medically stable but has a behavioral emergency condition. The physician calls for a crisis team to write a new hold and assist in arranging placement at a local referral center; however, the crisis team cannot arrive for hours (perhaps many hours). The police consider the transfer to be the responsibility of the hospital. The hospital calls the referral center, but the center does not want to accept the transfer unless the patient is on a hold — that is, legal authority to detain a psych patient involuntarily for a limited period of time. (This refusal may be an EMTALA violation, but this is not much help at the moment of crisis.) Compounding the problem is that the local ambulance company will not accept the transfer of an individual with a behavioral emergency in the absence of a hold because the patient may exercise his/her right to refuse the transfer during transport. And, the patient wants to go home. How should we handle this situation?

Answer: The above scenario, a scene now played out all too often in EDs, illustrates some of the incongruities between EMTALA and patients with behavioral emergencies, says M. Steven Lipton, an attorney with the San Francisco law firm Davis Wright. Since the early days of EMTALA, he notes, CMS has taken the position that hospitals are not relieved of their EMTALA obligations to screen, treat, or arrange for an appropriate transfer of emergent patients because of prearranged referral centers. As stated in the EMTALA Interpretive Guidelines:

"Hospitals are prohibited from discharging individuals who have not been screened or who have an emergency medical condition to nonhospital facilities for purposes of compliance with state law. The existence of a state law is not a defense to an EMTALA violation for failure to provide an [medical screening exam] or failure to stabilize an [emergency medication condition] …"

But that's the easy part, says Lipton. The hard part, he says, is making EMTALA work for behavioral emergency patients. Unlike most patients with medical emergencies, many hospitals do not offer psychiatric services or have psychiatrists or other behavioral clinicians on their medical staff. In addition, he notes, many states and local authorities have established laws on the detention, evaluation, and treatment of individuals who are a danger to themselves or others. Many of those laws fail to consider the EMTALA obligations in their application, such as:

• Behavioral screening. CMS has long taken the position that hospital emergency departments must provide a behavioral screening examination based on the presenting complaint, signs, and symptoms of a psychiatric patient. The documentation should include an assessment by the emergency physician (or other qualified medical person working under hospital policies) of suicidal or homicide risk, orientation, and other behavioral signs that indicate a danger to self or others.
  
  In locations where local agencies provide psychiatric crisis or evaluation teams, hospitals may use these to meet the hospital's obligation to provide further evaluation and treatment for patients with emergency conditions. However, warns Lipton, the use of crisis teams does not absolve the hospital from its obligation to conduct a screening, and monitor, assess, and treat (when indicated) an individual with a behavioral emergency until his or her departure from the hospital.
• Behavioral patient transfers. Hospitals may transfer behavioral emergency patients to referral centers, but only in accordance with EMTALA standards for an appropriate transfer if the patient's behavioral emergency is not stabilized, says Lipton. As noted in the EMTALA Interpretive Guidelines, a "sending hospital's appropriate transfer of an individual in accordance with communitywide protocols in instances where it cannot provide stabilizing treatment would be deemed to indicate compliance with …" EMTALA.
• Behavioral patient stabilization. Another problem, says Lipton, is determining whether a behavioral emergency condition is stabilized. The EMTALA Interpretive Guidelines provide that psychiatric patients are "considered stable when they are protected and prevented from injuring or harming him/herself or others." However, the guidelines also warn clinicians that the use of restraints for purposes of transferring a behavioral patient may only temporarily stabilize the emergency, and therefore practitioners "should use great care when determining if the medical condition is not fact stable" after administering restraints.
• Psychiatric holds. Many states have enacted legislation permitting designated clinicians and law enforcement officers to hold a psychiatric patient in custody pending evaluation and treatment at a referral center. Unfortunately, says Lipton, EMTALA does not authorize involuntary treatment for a patient who has capacity to refuse treatment, while state law may permit involuntary detention, transfer, and limited types of treatment for certain behavioral patients.

Some hospitals, Lipton notes, have been cited for EMTALA violations for failing to make an appropriate transfer when peace officers or crisis teams, having custody of behavioral patients under a legal hold, transport behavioral patients from an ED to a referral center. In addition, he says, the EMTALA rules permitting patients to refuse further evaluation, treatment, or transfer do not specifically address the rights of behavioral patients under state law holds, or worse, patients who dangerous to self or others who are not under a legal hold.

There is help on the way, says Lipton, noting that the EMTALA Technical Advisory Group (TAG), charged with giving input to CMS on EMTALA standards, is considering the application of EMTALA to behavioral patients. He hopes the TAG will propose more thoughtful guidance and direction as to how behavioral emergency patients should be treated under EMTALA.

From: ED Management

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Ask These Questions If You Suspect CO Poisoning

Patients with CoHb levels from 2%-5%:

• Do you smoke?
• How much do you smoke?
• When did you last smoke?

Patients who do not smoke and have COHb over 3%:

• What is your occupation?
• Do you work with industrial solvents or paint removers?
• How do you heat your home?
• Do you use a space heater at home?
• Have you been using a charcoal grill at home?
• Do you use gasoline-powered tools such as mowers, snow blowers, chainsaws, or weed trimmers?
• Have you had any recent exposure to exhaust fumes?
• Have you had any recent exposure to a fire?
• Does your home have a chimney?
• Have you been on a motorboat?
• Have you recently gone camping and used a gas stove?
• Are there any other family members, roommates, or co-workers with the same symptoms?

Source: Rhode Island Hospital, Providence.

From: ED Nursing

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Doctors More Likely To Tell When Patient Knows Error

Physicians in the United States and Canada generally report that they support disclosing medical errors to patients, but they have widely varying positions on when and how they would tell patients an error had occurred, according to recent work by Thomas H. Gallagher, MD, a researcher at the University of Washington School of Medicine in Seattle.

In many cases, the physician is likely to disclose the error only if the patient already knows something went wrong.

In a survey of 2,637 physicians from various specialties, the researchers presented the physicians with one of four scenarios involving a medical error. Two of the scenarios were tailored to internal medicine specialists, and two were tailored to surgeons. One of each type of error would be apparent to the patient, and the others would not be apparent to the patient if he or she was not informed.

For instance, the more apparent surgical error involved a sponge left inside a patient's body and the less apparent surgical error involved an internal injury that a surgeon inflicted because of unfamiliarity with a new surgical tool. The physicians answered a series of questions about the scenario they received, including how likely they would be to disclose the error, what information they would convey if they did disclose the error, how serious the error was, and how likely it was to result in a lawsuit.

Eighty-five percent of the physicians agreed that the error they received was serious, and 81% believed the physician was very or extremely responsible for the error. Overall, 65% would definitely disclose the error, 29% would probably disclose, 4% would disclose only if the patient asked and 1% would definitely not disclose. The language the physicians would use also varied widely. Forty-two percent would use the word "error," 56% would mention the adverse event but not the error, 50% would give the patient specific information about what the error was, and 13% would not reveal any details not requested by the patient.

From: Healthcare Risk Management

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