Penalties for Emergency Medical Treatment and Labor Act Violations Involving Obstetrical Emergencies

Introduction: The Emergency Medical Treatment and Labor Act (EMTALA) was intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (ED). While controversies exist regarding the scope of the law, there is no question that EMTALA applies to active labor, a key tenet of the statute and the only medical condition – labor – specifically included in the title of the law. In light of rising maternal mortality rates in the United States, further exploration into the state of emergency obstetrical (OB) care is warranted. Understanding civil monetary penalty settlements levied by the Office of the Inspector General (OIG) related to EMTALA violations involving labor and other OB emergencies will help to inform the current state of access to and quality of OB emergency care.Methods: We reviewed descriptions of all EMTALA-related OIG civil monetary penalty settlements from 2002-2018. OB-related cases were identified using keywords in settlement descriptions. We described characteristics of settlements including the nature of the allegation and compared them with non-OB settlements.Results: Of 232 EMTALA-related OIG settlements during the study period, 39 (17%) involved active labor and other OB emergencies. Between 2002 and 2018 the proportion of settlements involving OB emergencies increased from 17% to 40%. Seven (18%) of these settlements involved a pregnant minor. Most OB cases involved failure to provide screening exam (82%) and/or stabilizing treatment (51%). Failure to arrange appropriate transfer was more common for OB  (36%) compared with non-OB settlements (21%) (p = 0.041). Fifteen (38%) involved a provider specifically directing a pregnant woman to proceed to another hospital, typically by private vehicle.Conclusion: Despite inclusion of the term “labor” in the law’s title, one in six settlements related to EMTALA violations involved OB emergencies. One in five settlements involved a pregnant minor, indicating that providers may benefit from education regarding obligations to evaluate and stabilize minors absent parental consent. Failure to arrange appropriate transfer was more common among OB settlements. Findings suggesting need for providers to understand EMTALA-specific requirements for appropriate transfer and for EDs at hospitals without dedicated OB services to implement policies for evaluation of active labor and protocols for transfer when indicated

Test Characteristics of Urine Dipstick for Identifying Renal Insufficiency in Patients with Diabetes

Reprints available through open access a

Leadership and Teamwork in Trauma and Resuscitation.

Leadership skills are described by the American College of Surgeons' Advanced Trauma Life Support (ATLS) course as necessary to provide care for patients during resuscitations. However, leadership is a complex concept, and the tools used to assess the quality of leadership are poorly described, inadequately validated, and infrequently used. Despite its importance, dedicated leadership education is rarely part of physician training programs. The goals of this investigation were the following: 1. Describe how leadership and leadership style affect patient care; 2. Describe how effective leadership is measured; and 3. Describe how to train future physician leaders. We searched the PubMed database using the keywords "leadership" and then either "trauma" or "resuscitation" as title search terms, and an expert in emergency medicine and trauma then identified prospective observational and randomized controlled studies measuring leadership and teamwork quality. Study results were categorized as follows: 1) how leadership affects patient care; 2) which tools are available to measure leadership; and 3) methods to train physicians to become better leaders. We included 16 relevant studies in this review. Overall, these studies showed that strong leadership improves processes of care in trauma resuscitation including speed and completion of the primary and secondary surveys. The optimal style and structure of leadership are influenced by patient characteristics and team composition. Directive leadership is most effective when Injury Severity Score (ISS) is high or teams are inexperienced, while empowering leadership is most effective when ISS is low or teams more experienced. Many scales were employed to measure leadership. The Leader Behavior Description Questionnaire (LBDQ) was the only scale used in more than one study. Seven studies described methods for training leaders. Leadership training programs included didactic teaching followed by simulations. Although programs differed in length, intensity, and training level of participants, all programs demonstrated improved team performance. Despite the relative paucity of literature on leadership in resuscitations, this review found leadership improves processes of care in trauma and can be enhanced through dedicated training. Future research is needed to validate leadership assessment scales, develop optimal training mechanisms, and demonstrate leadership's effect on patient-level outcome

Factors Associated with Complications in Older Adults with Isolated Blunt Chest Trauma

Objective: To determine the prevalence of adverse events in elderly trauma patients with isolated blunt thoracic trauma, and to identify variables associated with these adverse events.Methods: We performed a chart review of 160 trauma patients age 65 and older with significant blunt thoracic trauma, drawn from an American College of Surgeons Level I Trauma Center registry. Patients with serious injury to other body areas were excluded to prevent confounding the cause of adverse events. Adverse events were defined as acute respiratory distress syndrome or pneumonia, unanticipated intubation, transfer to the intensive care unit for hypoxemia, or death. Data collected included history, physical examination, radiographic findings, length of hospital stay, and clinical outcomes.Results: Ninety-nine patients had isolated chest injury, while 61 others had other organ systems injured and were excluded. Sixteen patients developed adverse events [16.2% 95% confidence interval (CI) 9.5-24.9%], including two deaths. Adverse events were experienced by 19.2%, 6.1%, and 28.6% of those patients 65-74, 75-84, and >85 years old, respectively. The mean length of stay was 14.6 days in patients with an adverse event and 5.8 days in patients without. Post hoc analysis revealed that all 16 patients with an adverse event had one or more of the following: age ≥85, initial systolic blood pressure <90 mmHg, hemothorax, pneumothorax, three or more unilateral rib fractures, or pulmonary contusion (sensitivity 100%, CI 79.4-100%; specificity 38.6%, CI 28.1-49.9%).Conclusion: Adverse events from isolated thoracic trauma in elderly patients complicate 16% of our sample. These criteria were 100% sensitive and 38.5% specific for these adverse events. This study is a first step to identifying variables that might aid in identifying patients at high risk for serious adverse events. [WestJEM. 2009;10:79-84.

Building Interdisciplinary Teams in Emergency Care to Respond to National Emergencies: Addressing the Opioid Epidemic

This study responds to the gap in knowledge in translating team members’ interdisciplinary knowledge to address wicked problems. We use qualitative methodology to understand the team-building process and response to the opioid epidemic in emergency care. We collected data through direct observation of nine health system science researchers and thought leaders as they performed in team-building activities and semi-structured interviews. The cultural exchange framework informed our selection and assessment of team-building activities, and the science of team science (SciTS) framework informed our understanding of promoting interdisciplinary collaborations. We identified six themes representing three areas: (1) Knowledge Building and Strategy Development (need for interdisciplinary understanding of substance abuse and mental health in the emergency department (ED); interdisciplinary approaches to fight the opioid epidemic in the ED); (2) Team Demographics and Collaboration (prescribing and collaboration; the role of interdisciplinary team composition and effectiveness in the ED); and (3) Identity and Relationship Building (role of professional identity in contributing to interdisciplinary research; building effective organizational relationships in the ED). Members’ personal and professional connections are fundamental for developing nuanced interdisciplinary strategies to respond to the opioid epidemic in the ED. We discuss implications for strategies that promote team building and improve treatment practices

Patient Impression and Satisfaction of a Self-administered, Automated Medical History-taking Device in the Emergency Department

Introduction: We evaluated patient impressions and satisfaction of an innovative self-administered, hand-held touch-screen tablet to gather detailed medical information from emergency department (ED) patients in the waiting room prior to physician contact. Methods: Adult, medically stable patients presenting to the ED at Los Angeles County Hospital used the PatientTouche system to answer a series of questions about their current history of present illness and past medical/surgical histories in English or Spanish. Patients then completed a survey rating their experience. Results: Among 173 participants, opinion of PatientTouche was strongly positive; 93.6% (95%CI 90.0–97.3%) felt the physical product was easy to hold and handle, and 97.1% (94.6–99.6%) felt the questions were detailed enough for them to fully describe their condition; 97.8% (95.4–100.0%) felt using PatientTouche would help them organize their thoughts and communicate better with their physician, 94.8% (91.4–98.1%) thought it would improve the quality of their care, and 97.1% (94.6– 99.6%) expressed desire to use the product again in the future. Conclusion: The study was conducted at a largely Hispanic county ED, and only patients with 1 of 6 pre-determined chief complaints participated. We did not include a control group to assess if perceived improvements in communication translated to measurable differences. In this pilot study, patients were highly satisfied with all aspects of the PatientTouche self-administered, hand-held, touch-screen tablet. Importantly, subjects felt it would help them better communicate with their doctor, would improve their overall quality of care and overwhelmingly expressed a desire to use it in the future. [West J Emerg Med. 2014;15(1):35–40.

Test Characteristics of Urine Dipstick for Identifying Renal Insufficiency in Patients with Diabetes

Objective: To evaluate the test characteristics of the urine dipstick as a screening tool for elevated serum creatinine in patients with uncontrolled diabetes mellitus in the emergency department (ED).Methods: Patients with diabetes over the age of 18 who presented to the ED for any complaint over a three-month study period were considered eligible for participation in this study. A finger-stick blood glucose of ≥250 mg/dL at triage was used to confirm the diagnosis of uncontrolled diabetes. After obtaining written consent, each patient had a urine dip performed and a chemistry panel drawn. Any level of proteinuria on the urine dip was considered to be a positive test. Based on the laboratory and clinical guidelines at our institution, renal insufficiency was defined as creatinine concentration of greater than 1.3 mg/dL.Results: Three Hundred ninety-three confirmed patients with uncontrolled diabetes were enrolled in this study, and 49 of these (12.5%) were found to have renal insufficiency. The sensitivity and specificity of the urine dip for predicting renal insufficiency were 69.4% (95% confidence interval [CI] 54.6-81.7%) and 57.8% (95%CI 52.4-63.1%) respectively. The positive predictive value was 19% (95%CI 13.5-25.5%), and the negative predictive value was 93% (95%CI 88.7-96%). The positive likelihood ratio was 1.65 (95%CI 1.32-2.06) and the negative likelihood ratio was 0.53 (95%CI 0.34-0.81).Conclusion: In this cohort of patients with uncontrolled diabetes, the test characteristics of the urine dipstick make it a poor screening tool for renal insufficiency in the ED. [West J Emerg Med. 2011;12(2):250-253.

Patient Impression and Satisfaction of a Self-administered, Automated Medical History Taking Device in the Emergency Department

Introduction: We evaluated patient impressions and satisfaction of an innovative self-administered, hand-held touch-screen tablet to gather detailed medical information from emergency department (ED) patients in the waiting room prior to physician contact.Methods: Adult, medically stable patients presenting to the ED at Los Angeles County Hospital used the PatientTouche system to answer a series of questions about their current history of present illness and past medical/surgical histories in English or Spanish. Patients then completed a survey rating their experience.Results: Among 173 participants, opinion of PatientTouche was strongly positive; 93.6% (95%CI 90.0–97.3%) felt the physical product was easy to hold and handle, and 97.1% (94.6–99.6%) felt the questions were detailed enough for them to fully describe their condition; 97.8% (95.4–100.0%) felt using PatientTouche would help them organize their thoughts and communicate better with their physician, 94.8% (91.4–98.1%) thought it would improve the quality of their care, and 97.1% (94.6– 99.6%) expressed desire to use the product again in the future.Conclusion: The study was conducted at a largely Hispanic county ED, and only patients with 1 of 6 pre-determined chief complaints participated. We did not include a control group to assess if perceived improvements in communication translated to measurable differences. In this pilot study, patients were highly satisfied with all aspects of the PatientTouche self-administered, hand-held, touch-screen tablet. Importantly, subjects felt it would help them better communicate with their doctor, would improve their overall quality of care and overwhelmingly expressed a desire to use it in the future. [West J Emerg Med. 2014;15(1):35–40.