Chicago Hospital to Halt New Emergency Department Policies After Criticism

Kathleen Louden

March 16, 2009

March 16, 2009 (Chicago, Illinois) — After 2 national emergency physician groups took the unusual action of separately voicing concerns last month about emergency department (ED) policies at a large Chicago hospital — policies they believe could reduce patient access and quality of care — the hospital has said it will reconsider its policies.

At the center of the controversy is the University of Chicago Medical Center, which recently announced reorganization plans, including reducing the number of inpatient beds available to emergency patients by more than 30 and expanding efforts to redirect to other hospitals and clinics those ED patients who do not need emergency care. The tertiary care hospital, which has a high percentage of Medicaid patients, reported that about one third of the patients who come to its ED have nonurgent conditions. In a news release last month, the medical center said the changes, along with other cost-cutting measures, were needed to "meet today's financial challenges."

The University of Chicago Medical Center has decided to halt plans to redirect patients deemed nonurgent from its ED to other facilities, the Chicago Tribune reported on Saturday. The move came after external and internal protests of the plans.

Reorganization Opposed

Both the American College of Emergency Physicians (ACEP) and the American Academy of Emergency Medicine (AAEM) made public statements opposing the proposed reorganization. ACEP also questioned whether the south side medical center's treatment of a young dog-bite victim nearly violated the requirements of the Emergency Medical Treatment and Labor Act (EMTALA).

ACEP, the country's largest professional association of emergency physicians, commented on the individual case because its leadership believes the case represents a growing national problem, said the college's president-elect, Angela Gardner, MD. She spoke to Medscape Emergency Medicine in a phone interview.

"The concern of the American College of Emergency Physicians is that [more and more] hospitals across the country are taking measures that fulfill the letter of the law for EMTALA but decrease care for patients," said Dr. Gardner, an emergency physician at the University of Texas Medical Branch at Galveston.

The case involves 12-year-old Dontae Adams, who last August was attacked by a pit bull that allegedly tore off part of his upper lip. According to the February 13 Chicago Tribune, the boy's mother alleged that the University of Chicago ED physicians did not adequately treat her son because they did not want to accept his Medicaid insurance. The mother claimed that the ED staff gave the boy only painkillers, a tetanus shot, and an antibiotic prescription; refused to perform reconstructive surgery; and instructed them to follow up in a week with the county public hospital, John H. Stroger Jr. Hospital of Cook County, regarding possible reconstruction.

Instead, the mother immediately took her son by bus to Stroger Hospital on the city's west side, where Dontae underwent successful reconstructive surgery on his lip the same day.

The Tribune also cited the University of Chicago's plans to expand a "controversial program aimed at clearing its ER" of patients with nonurgent injuries and illnesses by redirecting them to community hospitals and clinics.

Emergency Physicians Speak Out

In a written public statement February 19, ACEP said "the University of Chicago Medical Center is failing in its obligation to treat emergency patients" and its policy toward emergency patients is "dangerously close to 'patient dumping.' "

Nick Jouriles, MD, president of the Dallas, Texas–headquartered ACEP and an Akron, Ohio, emergency physician, said in the statement, "This is a dangerous precedent that could have catastrophic effects in poor neighborhoods across the country."

University of Chicago officials said Dr. Jouriles did not attempt to verify the facts of Dontae's case. On its Web site, the medical center disputed ACEP's claims and reported that its pediatric ED physicians determined it was not medically appropriate to close the boy's wound at the time.

"He got the full treatment he needed here," said Robert Mulliken, MD, medical director of the adult ED and interim co-section chief of emergency medicine at the University of Chicago Medical Center, in a telephone interview with Medscape Emergency Medicine.

A hospital spokesperson said the boy's treatment included intravenous antibiotics, pain medicine, and cleaning and dressing the wound.

However, ACEP's Dr. Gardner said emergency physicians must consider not only legal obligations but also moral and ethical responsibilities to the patient.

"Every action we take as emergency physicians should pass the 'Aunt Betsy' test: 'Is it good enough for your Aunt Betsy?' " she said. "If not, I don't think it's something emergency physicians should be doing."

Days after ACEP's statement last month, the Milwaukee, Wisconsin–headquartered AAEM told the Chicago Tribune that the University of Chicago Medical Center should "re-evaluate its triage and screening examination policies."

AAEM President Larry Weiss, MD, JD, told Medscape Emergency Medicine in an email that the academy received information from University of Chicago physicians that the hospital had "drastically changed" the manner in which nurses and physicians perform triage and screening examinations in their ED. The doctors told them, "A physician is now directed by policy to discharge a patient at the time the physician determines that the patient is stable, rather than completing a diagnostic evaluation and providing admission or appropriate outpatient treatment," wrote Dr. Weiss, professor of emergency medicine at the University of Maryland School of Medicine, Baltimore.

"AAEM has a policy stating that an emergency department may triage a patient to another facility for treatment and follow-up care," he added. "However, this must be done in a safe manner. Hospitals should not merely tell patients to go to another hospital without proper referral."

"Triage Out": Pros and Cons

To do so is a form of "triage out" — sending low-acuity patients, after a medical screening examination, out of the ED to receive care at an urgent care center, clinic, or physician's office. One expert who spoke with Medscape Emergency Medicine called it the "push" system of triage out.

Arthur Kellermann, MD, MPH, chairman of the Institute of Medicine's planning committee for the National Emergency Care Enterprise workshops, described the "push" system: "We've looked you over. You're not that sick. Now go away."

The danger is that patients without private insurance often do not have access to care elsewhere.

"If we don't see them in the emergency room, they will not get the care they need, and some of them will come back much sicker," said Dr. Kellermann, professor and associate dean for health policy at Emory University School of Medicine in Atlanta, Georgia. "Most of my colleagues are unwilling to not treat [low-acuity] ED patients if they do not have reasonable assurance that the patients have someplace appropriate to go."

Still, advocates of triage out say it is more efficient and decreases misuse of the ED. The University of Colorado Health Sciences Center in Denver and its affiliate, Denver Health Medical Center, use a triage-out plan in their EDs. Christopher Colwell, MD, associate director of emergency medicine at Denver Health, told Medscape Emergency Medicine that the screening process works well there. Their program gives patients deemed as having nonemergent problems the option of going elsewhere and getting help making the appointment, or of receiving treatment in the ED but paying an insurance copayment or full payment up front.

The approach does, however, have limitations, he said. Any triage-out program must be blind to patients' insurance status before the medical screening examination, Dr. Colwell stressed. As a result, the ED will lose the revenue of any insured patients it screens out. Neither does the approach solve the problem of ED "boarding" due to lack of inpatient beds. Also, the triage staff could miss a true medical emergency.

Most emergency physicians who have not used triage out are uncomfortable with the concept, Dr. Colwell said, which he can understand. He said he sometimes thinks, "Selecting out patients we're not going to see goes against what our specialty is about."

A good way of screening out ED patients whose conditions are not emergent is a "pull" system, Dr. Kellermann said. Before discharge the hospital arranges accessible options for the patient, such as a medical home for primary care.

University of Chicago Tells Its Side

That is what the University of Chicago Medical Center is trying to do with its Urban Health Initiative and South Side Health Collaborative program, hospital officials said. The South Side Health Collaborative sends patient advocates into the ED — after treatment, if needed — to help patients with nonemergent conditions establish an ongoing relationship with a community health center or physician if they do not have a medical home.

By doing so, the medical center hoped to eventually reduce the long waiting times in its ED and to more quickly treat the severe injuries and illnesses that, as a level I trauma center, it is best equipped to handle, said Carolyn Wilson, RN, MBA, chief operating officer, University of Chicago Medical Center. At the same time, it would send business to partner hospitals and clinics that want to provide less complex urgent care and can do so at much lower cost than the academic hospital can.

"Our emergency department demand outstrips our capacity," she told Medscape Emergency Medicine in a phone interview. "Part of the controversy is that we're not trying to grow, like most hospitals. We're trying to be good stewards of limited resources across the south side [of Chicago]."

Most of the changes proposed for the ED have not yet occurred and are still being refined, Ms. Wilson said. The hospital did eliminate its urgent care center on February 8 and plans to add a resident physician to help the triage nurse. But the policy change announcement likely means that those plans are on hold.

The University of Chicago Medical Center, she said, is trying to create a national model for urban hospitals and to be a leader in finding solutions to the problems facing emergency care in the United States.

John Fildes, MD, chair of the American College of Surgeons Committee on Trauma and a University of Nevada trauma surgeon, agreed that the US emergency care system is broken. But he said, "The underpinning principle is that patients have to have access to care that is reliable, accountable, and affordable."

Some of the University of Chicago Medical Center's own physicians apparently consider patient safety threatened by the hospital's plans to decrease the number of inpatient beds available to emergency patients requiring admission. More than 190 fellows and residents from multiple specialties — including emergency medicine — protested the plan in a letter addressed to hospital trustees, The Wall Street Journal reported last week.

They wrote that "these changes directly violate our oath as physicians to do no harm."

None of the sources in this article reported any financial conflict of interest.

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