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

A palliative environment: Caring for seriously ill hospitalized patients

AbstractObjective:To explore how patients experience being in the hospital environment and the meaning they assign to the environment during serious illness.Method:A qualitative study design was applied, and the data analysis was inspired by Ricoeur's phenomenological-hermeneutic theory of interpretation. Data were collected through multiple qualitative interviews combined with observations at a teaching hospital in Denmark from May to September 2011. A total of 12 patients participated.Results:The findings showed that the hospital environment has a strong impact on patients' emotions and well-being. They reported that aesthetic decorations and small cozy spots for conversation or relaxation created a sense of homeliness that reinforced a positive mood and personal strength. Furthermore, being surrounded by some of their personal items or undertaking familiar tasks, patients were able to maintain a better sense of self. Maintaining at least some kind of familiar daily rhythm was important for their sense of well-being and positive emotions.Significance of Results:The results stress the importance of an aesthetically pleasing and homelike hospital environment as part of palliative care, since the aesthetic practice and a sense of homeliness strengthened patients' experiences of well-being, relief, and positive emotions while in a vulnerable situation. Such knowledge could encourage the development of new policies regarding appropriate care settings, which in turn could result in overall improved care during serious illness.</jats:sec

The role of GAGE cancer/testis antigen in metastasis: the jury is still out

BACKGROUND: GAGE cancer/testis antigens are frequently expressed in various types of malignancies and represent attractive targets for immunotherapy, however their role in cancer initiation and progression has remained elusive. GAGE proteins are expressed in normal cells during early development with migratory and invasive properties and were found to be upregulated in cancer cells with metastasizing potential in a gastric cancer model. METHODS: We have addressed the direct role of GAGE proteins in supporting metastasis using an isogenic metastasis model of human cancer, consisting of 4 isogenic cell lines, which are equally tumorigenic in immunodeficient mice, but differ with their ability to generate metastases in the lungs and lymph nodes. RESULTS: Although GAGE proteins were strongly upregulated in the highly metastatic clone (CL16) compared to non-metastatic (NM2C5), weakly metastatic (M4A4) and moderately metastatic clones (LM3), stable downregulation of GAGE expression did not affect the ability of CL16 cells to establish primary tumors and form metastasis in the lungs of immunodeficient mice. CONCLUSIONS: These results suggest that GAGE proteins per se do not support metastasis and that further studies are needed to clarify the contribution of GAGE proteins to the metastatic potential of different types of cancer cells

Pediatric Intensive Care from the Perspective of Parents: Experiences and Satisfaction with Person- and Family-Centered Care

The overall aim of this thesis was to investigate parents’ experiences and satisfaction with family-centered care (FCC)when their child was cared for at a pediatric intensive care unit (PICU). To obtain a deeper understanding of parents’experiences and satisfaction, two qualitative studies were conducted (Papers I and III). For Paper I, 10 individualinterviews were conducted two years after their child was cared for at a PICU. The interviews were analyzed usingcontent analysis. In Paper III spontaneous statements (n=70) obtained from the open questions in the questionnaireEmpathic-30 were analyzed (deductive and inductive) based on a thematic method. In order to further investigateparents' satisfaction with care from a family-centered perspective, the questionnaire Empathic-30, which is based onfamily-centered care, was translated and initially validated into Swedish (Paper II, n=97). Data from Paper II were alsoused to present the outcome of Empathic-30 (Paper IV). For Paper I data were collected from one out of four PICUsin Sweden and for Paper II, III and IV at two of the four PICUs in Sweden.Papers I and III focus on parents' experiences and satisfaction when the child was cared for in the PICU. The findingsshowed that parents of children in need of care at a pediatric intensive care unit experienced an emotional strain dueto, e.g. their child’s different appearance, the medical equipment that reduced their participation in their child’s careand the unfamiliar environment. Although the parents experienced the environment as frightening, they felt safe atthe PICU and had high confidence in the healthcare professionals taking good care of their child. The experiencesremained in the memory of the parents and were easily recollected. There were occasions when the experiencesresulted in ill mental health. The parents were satisfied with the care their children received at the PICU (Paper IV)and they felt they were treated with dignity and respect by the healthcare professionals (HCPs) (Paper I, II and IV).Although parents were highly satisfied with the care their child received, suggestions for improvements emerged. Thiswas mainly evident in the FCC concepts of information sharing particularly in connection with the child’s dischargeand participation in decisions about the child’s care