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When an elderly man presented with severe abdominal pain, the ED physician diagnosed a ruptured abdominal aortic aneurysm. However, the on-call surgeon refused to come in and insisted that a computed tomography scan be done first. Four hours later, another surgeon finally responded, but it was too late. The patient coded while being brought to the operating table and died. In another ED, a plastic surgeon demanded that a child’s parents sign a promissory note guaranteeing full payment before treatment for facial injuries from a dog bite — even after the parents paid him $2,000 in cash.
These scenarios may seem unthinkable, but similar incidents are occurring in EDs across the country, according to Loren A. Johnson, MD, FACEP, the ED medical director at Sutter Davis (CA) Hospital.1
There is a dangerous trend of specialists refusing to take call for the ED, partly due to increased liability risks for medical malpractice and violations of the Emergency Medical Treatment and Active Labor Act (EMTALA), reports Todd Taylor, MD, FACEP, an attending ED physician at Good Samaritan Regional Medical Center in Phoenix.
A new report from the Washington, DC-based General Accounting Office puts this crisis in the spotlight, concluding that inadequate ED on-call coverage is a growing problem in several states, including California, Arizona, Oregon, and Florida. (See "Resource," at the end of this article.) "This is a nationwide problem that is sure to get worse," says Johnson. "However, there is now a national dialogue, which may help the situation."
If you don’t take steps to ensure appropriate on-call coverage for your ED, you are at risk for violations and adverse outcomes, warns Kyle Weston, a consultant with the Washington, DC-based Clinical Initiatives Center, a health care organization that performs research for hospitals. "There are serious legal and quality concerns associated with not having adequate coverage," Weston says. (To see a sample on-call physician policy from the Clinical Initiatives Center, click here.)
Here are effective ways to improve your on-call coverage:
• Make sure staff can access the chain of command. If a consultant refuses to come in or can’t be reached, the ED physician must feel comfortable contacting the chief of staff, chief of service, and hospital administrator, says Johnson. "If they are gun-shy about doing this, it can cause significant delays and increase the risk of patient harm," he warns.
There must be a close working relationship among ED managers, ED staff, administration, and medical staff leadership, stresses Johnson. "This ensures that appropriate decisions for treatment or transfer can be made as quickly as possible," he says.
• Address patient transfers in your policy. To comply with EMTALA regulations, the hospital must accept transfers from other hospitals, but on-call specialists don’t have this obligation, says Johnson. "Very often, hospitals have not addressed this in their policy, which is a serious risk," he adds. If an ED on-call specialist refuses to accept a patient, then the hospital is at risk for a violation, he says.
Johnson points to a recent case at St. Anthony Hospital in Oklahoma City that resulted in the facility, not the on-call specialist, being cited for an EMTALA violation and fined $35,000. (Editor’s note: For more information, go to www.medlaw.com. Click on "Court Cases" and then on HHS v. St. Anthony Hospital.) Your hospital needs clear-cut policies and procedures to delineate these responsibilities and specify how specialty coverage will be provided, he says. "Hospitals are extraordinarily vulnerable to this loophole in the law," he adds.
• Don’t limit privileges of specialists. Many medical staff credential committees mistakenly believe that the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, requires specialists to drop their privileges for procedures they do infrequently, says Johnson. "This is leading to a loss of general specialty coverage for the ED." He recommends "categorical credentialing" to allow consultants to request special privileges for specific procedures and skills. "This is particularly valuable in community hospital settings without a huge number of specialists," he notes.
• Make sure the ED is represented at meetings. Insist on having a seat at the table when the medical staff and administrators are discussing on-call issues, urges Johnson. "You must ensure that these issues are dealt with in a comprehensive manner before individual problems occur, instead of sporadically," he says. As an ED manager, you should play an active role in improving education and clearing up misunderstandings, says Johnson. "It’s critical that the parameters of compliance and noncompliance be very well understood," he stresses.
• Avoid barriers to providing call coverage. Medical staff bylaws and departmental rules and regulations may create problems, according to Johnson. "For example, the bylaws may simply state that coverage will be determined by each service or department of the medical staff," he says. "By vesting this authority in a dysfunctional service or department, the coverage may fall through the cracks." Instead, there should be an umbrella requirement for participation in ED call coverage that applies to the entire staff, says Johnson. "This gives the chief of staff the authority to assert that the department will provide coverage, despite day-to-day discontent," he says.
• Consider fee-for-service arrangements. On-call physicians frequently are given stipends to provide coverage for the ED, notes Joseph Viglotti, MD, FACEP president of Emergency and Acute Care Medical Corp. in La Jolla, CA. "This often gets out of control, when the amount of money you are paying and the number of physicians who want a stipend become too much," he says.
Some California hospitals are paying neurosurgeons up to $2,000 per day as a stand-by fee, even though these physicians usually receive only two calls per month from the ED, notes Weston. In some cases, a fee-for-service payment guarantee practice is a better option, says Weston. "It is the most intelligent and fair approach to addressing the problem," he adds. "Tying payment to the actual level of service provided in the ED protects the hospital from unnecessary expense."
• Use a "chain-of-command" call ladder. Have a prearranged, backup call system so that alternate specialists can be called if a consultant does not respond in a timely manner, Weston recommends. This provides an immediate solution when physicians don’t respond, he says. "Perhaps more importantly, the threat of a call to the chief of service or hospital administrator motivates most physicians to speed up their response times to under 30 minutes," Weston adds.
• Take steps to coordinate physician specialty services. Having 10 ophthalmologists on-call at 10 hospitals is a terrible waste of resources, compared with two ophthalmologists covering all 10 hospitals on a given night, says Taylor.
Taylor points to a trend of physicians forming consortiums. "For example, a group of ophthalmologists might form an on-call ophthalmology consortium’ to coordinate on-call services for several hospitals in a region," he suggests. "Each hospital would contribute a small amount of money for stand-by coverage," Taylor says.
• Implement a quality assurance (QA) program. Consider tracking individual consultants on their responsiveness to the ED, says Weston. "An on-call physician QA program can be a highly effective strategy for speeding consultant response times," he says. "This is relatively easy to do and highly effective."
Physicians receive a "departmental report card" that compares their response time with the response times of other physicians, who are anonymous, says Weston. This provides consultants with direct peer-group comparisons, he explains. Physicians will want to match or outperform their peers, says Weston. There is also fear of the financial penalties that can be levied by the Centers for Medicaid and Medicare Services, formerly the Health Care Financing Administration, if the physician is found in violation of EMTALA, he adds.
1. Johnson LA, Taylor TB, Lev R. The emergency department on-call backup crisis: Finding remedies for serious public health problems. Ann Emerg Med 2001; 37:495-499.
The U.S. General Accounting Office report, titled Emergency Care: EMTALA Implementation and Enforcement Issues, can be downloaded from the GAO web site (www.gao.gov). Click on "GAO Reports" and then on "Search GAO Archives." Under "Report title," enter the name of the report. Single copies are available at no charge. To order a copy, contact: U.S. General Accounting Office, PO Box 37050, Washington, DC 20013. Telephone: (202) 512-6000. Fax: (202) 512-6061.
For more information about on-call coverage, contact:
• Loren Johnson, MD, FACEP, Emergency Department, Sutter Davis Hospital, 2000 Sutter Place, Davis, CA 95617. Telephone/fax: (530) 756-6036. E-mail: firstname.lastname@example.org.
• Todd B. Taylor, MD, FACEP, 1323 E. El Parqué Drive, Tempe, AZ 85282-2649. Telephone: (480) 731-4665. Fax: (480) 731-4727. E-mail: email@example.com.
• Joseph Viglotti, MD, FACEP, Emergency and Acute Care Medical Corp., 7514 Girard, 1PMB431, La Jolla, CA 92037. Telephone: (858) 454-5448. Fax: (858) 454-6257. E-mail: firstname.lastname@example.org. Web: www.eacmc.com.
• Kyle Weston, Clinical Initiatives Center, 600 New Hampshire Ave. NW, Washington, DC 20037. Telephone: (202) 672-5685. Fax: (202) 672-5700. E-mail: WestonK@advisory.com.