As the name suggests, emergency rooms (ER) are intense places. Triage nurses perform a quick assessment of patients to determine who needs seen most urgently. ER physicians, physician assistants (PAs), and nurse practitioners (NPs) evaluate patients and order testing to determine which patients need admitted to the hospital and those who should be discharged home.
One of the important determining factors concerning discharges is whether a patient is medically stable. The federal Emergency Treatment and Active Labor Act (EMTALA) was signed into law by President Ronald Reagan to prevent patient dumping. EMTALA requires accredited hospitals to perform a standard medical screening, without regard to the ability to pay, for a patient who presents to the ER in a bona fide emergency medical condition or in active labor.
The federal statute doesn’t require the hospital to provide a full array of treatment, including surgery or curative care, unless is needed to stabilize the patient. Patients are considered stabilized when they can be transferred to another hospital or discharged home without a material deterioration of their health status.
An easy way to look at the requirements for ER personnel is that they have to screen and stabilize a patient in an emergency medical condition but can discharge them from the ER as soon as they are stabilized. This doesn’t mean that patients being discharged can’t have ongoing medical conditions—even serious ones. Rather, the patients just need to be stabilized such that they can follow up with their regular physician or provider in a non-ER setting.
It’s at this point that the critical importance of discharged instructions and communications come into play. As a Houston, Texas medical malpractice lawyer, this is where I see the ball drop frequently.
Registered nurses typically share discharge instructions verbally and in writing. At a minimum, discharge instructions should include the diagnosis and treatment from the ER stay or hospitalization, a list of any prescriptions that need to be filled, details of any home health needs and providers that have been contacted, and what to do if the patient develop certain symptoms.
As a patient, it’s important to be engaged with the nurse in the discharge planning conversation and to review the written discharge instructions carefully. We’ve handled several cases where patients were being discharged with active symptoms that were listed on the discharge instructions as warranting a return to the emergency room. If that happens, it’s important to speak up!
Discharge instructions also provide information on follow-up medical appointments that the patient may need. Remember, any ER visit or hospitalization ends when the patient is stable, but that doesn’t mean that all medical conditions have been resolved. It also doesn’t mean that follow-up care might not be necessary.
I recently read a report about a medical malpractice wrongful death case that our firm didn’t handle. It illustrates the dual responsibilities of medical and nursing providers and patients.
A man in his 50s died about three weeks after being seen in a hospital emergency room with a one-day history of chest and abdominal pain. The ER physician ordered an EKG cardiac rhythm strip, lab work, and a chest x-ray, and felt that the results showed nothing abnormal. The doctor then discharged the patient from the ER with a diagnosis of chest wall pain and provided discharge instructions to see his primary care provider in two or three days.
The discharge instructions also stated that a radiologist would review his chest x-ray and that he will be notified if the radiologist saw something different than what the ER physician felt were normal findings. As it turns out, the radiologist felt that the chest x-ray showed an enlarged heart (cardiomegaly) and sent a report to both the emergency room and the patient’s primary care provider.
The patient didn’t follow-up with his primary care provider, as recommended the hospital discharge instructions, and died three weeks later from a cardiac arrhythmia.
The case went to trial. It’s clear to me that the emergency room personnel and primary care provider should have picked up the phone and called the patient. That’s what the plaintiffs argued.
The defendants countered by presenting evidence that an enlarged heart is a chronic problem, not an emergency medical condition. The hospital policy required the on-duty emergency physician to review radiology reports and only notify the patient if there are changes that would lead to a change in management.
Do you care to guess what the jury found?
The jury decided that the discharge instructions didn’t establish the standard of care for the hospital or health care providers. They found for the defendants and the trial court decision was upheld on appeal.
It’s hard to say how a different jury would decide this case. What is clear, though, is that hospitals, doctors, health care providers and patients all know to play their role in ensuring a continuity of care by having accurate discharge instructions that are followed.
If you’ve been seriously injured because of poor medical care in Texas, then contact an experienced, top-rated Houston, Texas medical malpractice lawyer for help in evaluating your potential case.