Review ED policies, training on EMTALA, proper discharge after viral video


March 1, 2018

Use the video of a woman wearing only a hospital gown and socks left on a recent cold night by security guards at a bus stop outside a Baltimore hospital as a training tool to review expectations for dealing with difficult cases at your facility’s Emergency Department.

After video of the woman standing dazed and barely able to walk at the bus stop was posted to social media and went viral — one news report said it was viewed more than 2.3 million times on Facebook — University of Maryland Medical Center Midtown Campus’ CEO Mohan Suntha promised a full investigation into what he termed “a failure of basic compassion and empathy.”

The video was taken by a man who said he witnessed hospital security guards wheel the woman in a wheelchair to the bus stop. The man confronted the guards, who said the woman had been medically discharged.

Other than the statement from Suntha saying that the hospital was still “trying to understand the points of failure that led to what we witnessed on that video,” details of exactly what brought the woman to the hospital, her condition, any treatment or other information was not released, citing patient confidentiality.

The man who recorded the video called police, who had an ambulance take the woman back to the hospital, from which she was ultimately sent to a homeless shelter and finally picked up by family members. The Washington Post later talked to the woman’s mother, who said the patient had a history of mental illness.

While there are a lot of “what ifs” about the incident, “we technically don’t know what happened during the encounter,” notes Frank Ruelas, a patient safety professional and HIPAA consultant who founded HIPAA College in Arizona. “However, there is enough information for us to consider asking questions on how we may have managed this patient if she had presented at our respective ED within our respective hospitals.”

Regulatory considerations with such a patient would fall under the Emergency Medical Treatment and Labor Act (EMTALA) as well as discharge planning expectations, says Ruelas.

EMTALA expectations considerable
EMTALA, in general, requires hospitals to care for patients with emergent conditions, regardless of their ability to pay. Violations of EMTALA are often cited by CMS surveyors under patients’ rights or failure to do an adequate medical screening exam.

In addition to potentially impacting a hospital’s accreditation or ability to bill Medicare, EMTALA violations can also come with a civil penalty, which can top out at almost $105,000 for each citation. And hospitals can face several fines related to just one patient, notes Sue Dill Calloway, president of Patient Safety and Healthcare Consulting and Education in Dublin, Ohio.

While media coverage of the viral video mentioned possible concerns with so-called “patient dumping,” an EMTALA violation, there may not have been a specific violation under that regulation, says Ruelas.

“Generally speaking, and not going into some of the more technical aspects of the regulations, EMTALA requires that when a person presents at a dedicated emergency department that a medical screening exam (MSE) is done to determine if a patient has an emergency medical condition (EMC). If the patient ultimately ended up in a homeless shelter, it was likely she did not have an EMC,” Ruelas says, responding to questions through e-mail. If the patient did have an EMC, the hospital would have been required to either admit her or arrange “for an appropriate transfer as required by EMTALA.”

CMS sets out Interpretive Guidelines for surveyors to implement EMTALA regulations in State Operations Manual Appendix V. Under EMTALA, says Ruelas, “when the patient presented, there should be documentation to show the date and time when the patient arrived in the ED. This is often noted in what is called under the EMTALA regulations as a central log. The log would also indicate whether the patient refused or denied treatment.”

“Once that patient arrived and was noted in the log, there would then be documentation to show the initiation of an MSE and what was done to assess the patient to determine if the patient had an EMC. This should include evidence of diagnostic work or tests that were done that would have provided information to the health care team about the patient’s condition,” notes Ruelas.

“There should then be documentation to show that the qualified medical professional made a decision as to whether an EMC existed and then steps taken in response to the EMC, or if no EMC existed, then steps to discharge the patient. I believe this is where there may have been a breakdown,” Ruelas says.

Document patient handoff and discharge
In addition to meeting expectations outlined in Appendix Z, hospitals must also continue to meet the Conditions of Participation (CoP) outlined in Interpretive Guidelines in Appendix A (SOMA), notes Ruelas.

“Appendix A requires that all patients have a discharge plan. Essentially, the discharge plan takes into account the patient’s health condition and general situation, which in turn helps formulate the discharge planning process for individual,” says Ruelas.

A patient encounter such as this may help facilities focus reviews of their own process for handling patients in the ED. Here are two key questions facilities should ask, according to Ruelas:

1. Can we show for every patient that presents in the ED a clear pathway from when the patient presented to the time the patient was discharged?

2. Can we show that the discharge of the patient was consistent with our assessment of the patient’s condition and their present situation?

The need for documentation, while often considered onerous, can be your friend, especially in the aftermath of cases involving patients with difficult needs.

This is “an area that lends itself easily to a very straightforward and meaningful audit. The audit can determine if a discharge plan was in place and documented for the patient, to include such contingencies [as] whether the patient refused care, was non-compliant, abusive, cooperative, or other factors that may impact a person’s willingness to participate in the development of their discharge plan.”

Review expectations with staff
Every emergency department deals with difficult cases. Regardless of the circumstances of the ED’s capacity to deal with an emergent medical condition or with a patient who is non-compliant, it’s important to be able to show how staff dealt with a patient on a case-by-case basis, says Ruelas.

“Whether the patient was difficult or not, were the same steps followed that provided the difficult patient the same opportunities as that of a patient that was fully compliant? This also includes, though rarely discussed openly — but I think people do realize there could be a difference — reviewing the discharge plans for insured individuals and non-insured individuals, again to see if, though the outcomes may have been different due to the insurance element, was the discharge plan appropriate for each patient, all other things considered?” says Ruelas.

Ensure your staff is educated and trained in handling a variety of patients, recognizing certain behaviors and know what steps they can take to diffuse that behavior, he says.

“For example, anxiety can certainly make people feel agitated and cause them to act in a way that could appear difficult,” he says.

Despite even the best of efforts, “there are people that will be difficult no matter what you do. In these cases, I think the staff, depending on the situation and circumstances, needs to have a consistent and well understood escalation plan,” advises Ruelas.

An example path for that plan, says Ruelas, might be “RN → Charge Nurse → House Supervisor → Security → Law Enforcement.”

While the circumstances that lead to what was seen in the video are likely to remain unknown, at least for now, similar incidents can be headed off at your facility.

“I genuinely believe that if the hospital where this patient presented had combined its efforts of meeting its EMTALA obligations along with its obligations to meet the other regulations that applied to the hospital, it is logical to think that the patient would have still been discharged but that she would have been discharged and transported to the homeless shelter and not have been escorted out of the hospital and taken to the bus stop as seen in the video,” says Ruelas.

CMS State Operations Manual, Appendix V, “Responsibilities of Medicare Participating Hospitals in Emergency Cases:”
CMS State Operations Manual, Appendix A, “Survey Protocol, Regulations and Interpretive Guide-lines for Hospitals:”
Washington Post, Jan. 12 article on viral video:

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