When Theresa Penn experienced crushing chest pain, she went to her family physician’s clinic in her home town. He diagnosed ACS and AMI and attempted to arrange a direct admit to a cardiologist at the nearest hospital. The on-call cardiologist refsued the case because the intensive care unit was full, so the physician sent the patient some distance to the next facility. During transport, Mrs. Penn suffered an arrest and emergency personnel were unable to revive her. The family filed suit alleging the local hospital violated EMTALA.
So, is turning away a request for direct admit from a physician’s office an EMTALA violation? The court in the this case ruled that EMTALA did not apply because the patient never presented to the hospital as defined by EMTALA and CMS regulations, and there was no room in EMTALA to “imply” duties that did not fit the definititions. Had the patient entered a hospital-owned ambulance or presented to the hospital, EMTALA would have been applicable, but not in a physician’s private office. This case is consistent with CMS advice in previous EMTALA cases.
While we cannot say with certainty that Mrs. Penn would have survived if things had been handled differently, the case outcome follows a frequent scenario seen in cases where the patient is in a doctor’s or dentist’s office when the emergency occurs. Office-based providers are not used to dealing with emergencies outside the hospital and often either over-manage or under-appreciate the situation. In this case, there was a simple and effective way to assure that the patient went directly to the nearest facility and that the on-call cardiologist would see the patient — call the ambulance and send the patient to the hospital. Attempting to set up a direct admission was over-management and actually set up the scenario for failure.
Another frequent scenario is jamming the critically ill patient into the family car and instructing the family to drive to the hospital. That option very rarely makes sense compared to calling 9-1-1. The hard part about calling 9-1-1 from the doctor’s office is the seemingly endless wait as seconds pass like hours awaiting the arrival of the ambulance and attempting to manage the unexpected situation. Once the ambulance arrives, however, the office staff and provider need to step back and let the emergency-trained staff do their jobs.
The first big mistake in managing this emergency, however, was not that of the doctor or the hospital. That mistake was the decision by the patient to go to her family doctor for chest pain (or other serious symptom) instead of calling 9-1-1 and being in the ED or in the ambulance when the arrest struck. The location and timing could have made all of the difference.
Penn v. Salina Regional Health Center, Inc. (D.Kan)