Patient dumping remains a concern for nation’s EDs

At the same time, hospitals routinely fail to implement strategies that could reduce boarding.

By — Posted Aug. 27, 2012

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Despite the federal law that bars emergency departments from refusing to treat patients with acute medical conditions, lax enforcement and monitoring allow patient dumping to continue, argue the authors of a case study in the August Health Affairs.

In a separate article in the journal, a group of emergency care experts argues that many hospitals have been slow to take action to address patient boarding. The practice occurs when an emergency physician has admitted a patient to the hospital but the patient remains in the ED because there is no inpatient bed available.

The patient dumping article was co-written by legal and health policy experts as well as two physicians from Denver Health Medical Center. The article discusses five cases in which the hospital received patients from other hospitals that could be considered examples of dumping.

For example, a 30-year-old woman who was having trouble breathing and swallowing went to the ED of a suburban Denver hospital and was found to have an abscess at the base of her tongue that was encroaching on her airway. The hospital contacted the specialist on call for surgery, but he refused to perform the procedure because the patient was uninsured.

Denver Health took on the patient and delivered uncompensated care worth nearly $16,000, then reported the case as a violation of the Emergency Medical Treatment and Labor Act. The federal law was enacted in 1986 after several widely reported cases of patient dumping. In the Colorado case, the state upheld Denver Health’s report as an EMTALA violation.

There is little empirical evidence to demonstrate how widespread dumping is, the authors acknowledged. That, they argue, is part of the problem with the current regulations. Patients may be unaware that dumping is happening. Safety-net hospitals, meanwhile, may fear that filing complaints would upset relationships with other area hospitals.

“Obviously, there’s a need for much more enforcement, and for the federal government to come up with a way of monitoring the EMTALA activities of hospitals to get a better estimate of how many people come to seek care and leave without even a screening,” said Sara Rosenbaum, co-author of the article and professor of health law and policy at George Washington University in Washington.

Rosenbaum and her co-authors argue that clearer standards are needed to determine what constitutes appropriate screening and stabilization under the law. They also said hospitals should be barred from asking for insurance information until after care has been rendered because the screening process can lead to dumping.

The American College of Emergency Physicians referred an interview request to Wesley Fields, MD, chair of the Emergency Medicine Action Fund, a federal regulatory advocacy coalition of emergency medicine and physician organizations created in 2011. Dr. Fields declined to discuss individual cases of alleged dumping, but he said that standards for screening and stabilization under EMTALA are likely to evolve in light of the Affordable Care Act.

“It would be worthwhile for [the Centers for Medicare & Medicaid Services] to reconvene stakeholders in the acute care system to engage around some of these issues, because they don’t figure to go away,” said Dr. Fields, an emergency physician at Saddleback Memorial Medical Center in Laguna Hills, Calif. He added that making EMTALA enforcement standards more consistent and predictable would help protect the uninsured as well as the hospitals and physicians providing emergency care.

Boarded patients get worse care

Another problem in emergency care is patient boarding. A 2010 survey cited in the Health Affairs article found that nearly 85% of hospitals reported boarding patients in the seven days before the survey.

The practice crowds the ED and delays emergency care for other patients, the article said. It also harms the boarded patients, prolonging illnesses and worsening outcomes for patients with cardiac conditions and stroke, and increasing the risk of hospital-acquired infections and death.

Strategies such as having a point person to coordinate bed availability can help, yet only half of hospitals do that, the article said. A third of hospitals do not have real-time information available about bed availability. Most hospitals schedule elective surgeries only during weekdays, making it more difficult to find an inpatient bed because many are reserved for patients recovering from surgery.

“We’ve not seen a lot of movement by many hospitals to do something about the boarding issue, and it’s now become almost routine,” said Sandra Schneider, MD, past president of the American College of Emergency Physicians. She was not involved in writing the Health Affairs article on boarding.

To qualify for a full payment update from CMS, hospitals are required to report their performance on several measures related to crowding and boarding. These include the median time from the admit decision to departure from the ED, which hospitals will be asked to report starting in October 2013.

Several other countries have adopted standards limiting boarding. The United Kingdom, for example, bars boarding a patient for longer than four hours. Such action may be needed in the U.S. if hospitals do not improve, said Dr. Schneider, an emergency physician at Strong Memorial Hospital in Rochester, N.Y.

“Hospitals are reacting to the stresses that are on them in terms of getting enough staff, getting beds open, adding more beds,” she said. “We don’t discount that. We sympathize with them, but the answer is not keeping patients in the ED, because that’s bad for patients.”

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9 ways to cut ED boarding and crowding

Emergency medicine experts argue that too many hospitals are failing to implement methods shown to help ED patients get admitted to inpatient beds more quickly and reduce crowding. They recommend that hospitals:

  • Move boarders to inpatient halls, which places them in a quieter, less crowded, safer setting while freeing ED beds.
  • Distribute elective surgical and catheterization schedules evenly over the week to decrease demand peaks for inpatient beds and the need to cancel procedures.
  • Schedule cardiac catherization earlier in the day to free up inpatient beds.
  • Assign a “bed czar” to closely track bed use and address bottlenecks into and out of beds using a computerized system.
  • Create a “discharge lounge” where inpatients who no longer need a bed can stay while awaiting discharge.
  • Aggressively manage and expedite inpatient discharges to speed up planning for home services and outpatient placement.
  • Monitor turnaround time of bed cleaning to improve flow of patients into inpatient rooms.
  • Simplify admission protocols so it is easier to transfer ED patients to inpatient floors.
  • Use a “reverse triage” system where patients with the least need for inpatient beds are discharged to make room for ED boarders.

Source: “Solutions To Emergency Department ‘Boarding’ And Crowding Are Underused And May Need To Be Legislated,” Health Affairs, August (link)

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External links

“Case Studies At Denver Health: ‘Patient Dumping’ In The Emergency Department Despite EMTALA, The Law That Banned It,” Health Affairs, August (link)

“Solutions To Emergency Department ‘Boarding’ And Crowding Are Underused And May Need To Be Legislated,” Health Affairs, August (link)

“National Trends in Emergency Department Occupancy, 2001 to 2008: Effect of Inpatient Admissions Versus Emergency Department Practice Intensity,” Annals of Emergency Medicine, June 20 (link)

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