When the patient presented for vague symptoms, the ED ordered a blood test to rule out cardiac issues, but according to published reports on the trial, the patient was sent home.
The news story indicated that the results came back the next morning, and the ED nurse called the patient and her notes indicated that she told the patient his results were “positive” and that he should return to the hospital. She noted the patient did not want to return to the hospital. The patient reportedly testified he remembered a call but not what was said, while the patient’s attending noted his impression from talking to the patient as the tests were “negative”. The patient required surgery 8 months later to repair avoidable heart damage.
The blood test results were never sent to the attending, and in spite of ongoing issues the attending never requested the test results. The fact that the attending was unaware of the critical values found in the blood test led the physician to pursue a cancer diagnosis rather than a cardiac diagnosis. The hospital admitted it had “made a mistake” and the case went to trial on the amount to be awarded.
The jury awarded $600,000 for medical expenses, $500,000 for pain and suffering, and $1 million for permanent injury. They deducted $315,000 for the patient’s failure to return to the hospital when called. News reports indicated that a further reduction is expected, due to a pre-trial agreement that medical expenses would be capped at $293,867.
So, what are the take-aways from this case for your ED operation?
- Your policies and procedures for critical lab values should assure that the patient, the ED physician, and the private attending are all notified of a critical value by phone — especially if the patient has been sent home
- Written notification by fax or EHR to providers and by mail to the patient should also be made — especially when the patient is refusing to come back to the ED
- Detailed notes should made documenting in careful detail all notifications or attempts at notification
- Do not note or speak in medical terms like “negative” and “positive” — terms often have different meanings on different tests — especially when talking to a lay person who may think “positive” is “good” and “negative” is “bad,” when it could be just the opposite.
- Wouldn’t you want to have an atmosphere on your ED team that if a nurse called a patient with an critical message to return to the ED that it would immediately move up the chain of command if the patient refused to come back?
On a final note, this case did not involve any EMTALA claim, but it DOES — at least if CMS had been aware of it. The case of the critical cardiac values parallels an actual EMTALA citation for one of my hospitals.
The scenario involved a male in his early 50’s who came in complaining of chest pain. Chest X-ray, EKG, and blood enzyme tests were ordered. The chest X-ray and EKG came back without any obvious irregularities. Then the shift changed. The new ED physician discharged the patient without waiting for the blood test results with a diagnosis of “chest pain, non-cardiac”. Several hours later, the STAT blood test came back with markedly elevated values, and immediate attempts were made to contact the patient. When the hospital contacted the patient’s home, the patient had just left by ambulance after collapsing. The patient was DOA at another hospital.
CMS took the position that with the exception of something like a blood culture which takes several days to get results on, tests ordered in the ED must be back and evaluated by the physician before the patient can be discharged. Their logic was that if the physician considered the test important enough and necessary enough to the diagnostic process to order, then they cannot make a determination of whether or not an emergency medical condition exists without having the results. Without a determination of whether or not an emergency medical condition exists, you cannot make a discharge under EMTALA.