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Diversion scheme draws national organizations' ire
Hospital might reconsider its policy
Several EDs across the country have initiated policies to encourage patients who don't face "true" emergencies to seek care elsewhere in the community and to find "medical homes," but none have been met with the outrage that descended upon the University of Chicago Medical Center recently. The Chicago Tribune reported that under a new policy, the hospital was "escalating steps to direct these consumers elsewhere, which it says will allow it to focus on treating the sickest of patients."1
Reaction from within the industry was swift and uncompromising. In a prepared statement, leaders of the American College of Emergency Physicians (ACEP) said the university was "dangerously close" to a "patient-dumping" policy that would violate the Emergency Medical Treatment and Labor Act (EMTALA). ACEP said that several emergency physicians and the ED director resigned over the new policy.
The American Academy of Emergency Medicine (AAEM) said the University of Chicago should "re-evaluate its triage and screening examination policies."
As this issue went to press, an internal hospital memo indicated the facility was, indeed, "reconsidering" its policy,2 but ACEP and AEEM leaders remained skeptical. What's more, they say, such a re-evaluation would not negate some of the actions already taken. They also expressed concern that other facilities, facing growing financial pressures, might consider similar actions.
"It's good that they're listening to public constructive criticism, and perhaps even listening to their own ED physicians and nurses, whereas initially this was done without any input from clinical people," notes Larry D. Weiss, MD, JD, FAAEM, president of the AAEM, a professor of emergency medicine at the University of Maryland in Baltimore, and an attending ED physician at the University of Maryland Medical Center. "Several of our members who work there said they were not considered at all — that the policy was developed by administrative personnel," he says. Such an approach is tantamount to "changing the way the operating room works without consulting the surgeons," Weiss adds.
Weiss' objections extend to the new triage policy itself. "It's our understanding that if, during the screening exam, the physician determines the patient to be stable, they are directed to discharge them," he says. "But there are many stable patients who require admission, and the idea that they would turn away stable patients violates national standards of practice." For example, Weiss offers, a patient with a gallstone could be in a lot of pain but not have an infection, or someone with pneumonia might have stable vital signs. "Where do you draw the line?" he asks.
University's plan went too far
What the University of Chicago was doing went beyond what many other facilities have done, says Sandra Schneider, MD, an ACEP vice president. "What they did was, in order to maintain their financial status, they looked at the types of patients that added dollars to the hospital and made inpatient beds available to them while cutting down on the number of beds available to regular emergency treatment," says Schneider, who also is a professor of emergency medicine at the University of Rochester (NY) and an attending ED physician at Strong Memorial Hospital, also in Rochester.
Schneider says such a policy might not violate EMTALA, as long as the patients who are diverted don't have an emergency medical condition. However, there is a moral obligation to see them, she says. Schneider argues that most of these patients are not "taking advantage" of the ED, which many assert is the case. "Our literature shows us that many of these people do not go on to get treatment," she says. "Those who choose to come to the ED often do so because there is no other option, either there are no clinics available or those that are available are not open at the times they can get there."
As for the latest news about the hospital, "we do not know what they have come up with, although we're happy they are reconsidering the policy," says Schneider, who adds, "We'd be glad to meet with them and talk about it."