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Emergentology: EMTALA 2.0

Walker, Graham, MD

doi: 10.1097/01.EEM.0000529869.92776.5d
Emergentology

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns at http://bit.ly/EMN-Emergentology.

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We all know that EMTALA is an unfunded mandate from the federal government requiring us to provide service without any financial support. “Make it work,” said the Department of Health and Human Services, and made it work we have. This mandate has dramatically changed how the health care system works—how and where our patients receive care and the charges and payments for that care. Worst of all, it made our EDs a political and financial battleground. Everyone knows you can receive attention with less waiting and red tape in an ED than anywhere at any hour, and that makes us the path of least resistance for any health problem.

My friends who have practiced in less-advanced countries view EMTALA differently from those of us in the United States. They tell stories of pulling dead children from cars because the first two hospitals refused them care. They repeat instances of arguing with patients about whether a test was necessary because patients had to pay upfront. They view EMTALA as a privilege and sign of wealth and value of human life. Receiving help after walking into a hospital doesn't exist everywhere in the world.

My research on EMTALA and its effects has complicated my views on it. People are always going to take advantage of policies, but would we be worse off if we repealed EMTALA because of its abusers? Should we get rid of handicapped parking because some people abuse the placards? I'm not going to answer these deep questions here, but I came up with several ideas about what would help my practice.

We should have harsh punishments for violence against emergency providers and first responders. We should mandate that violence against those dedicated to saving lives will not be tolerated. Enough is enough. Get the word out that you can't be violent against health care providers. It should be like saying “bomb” at the airport or making a threat against the president. And we should call for punishment, not jail time. Jail will not have the same effect on a drunk, violent teenager as community service or a $10,000 fine.

We currently cannot do or say anything that might prevent a patient from seeking care prior to a medical screening exam. This infantilizes our patients, assuming they're too dumb to make an educated decision, and adds significant stressors for everyone by not allowing expectations to be set at the door. Is it still a surprise that patients may wait in the ED? Would it really be unsettling to post an estimated wait time so patients can be informed and arrange child care or tell work they'll be late? Disney lets guests decide which attraction to ride by giving them wait times. The DMV and the deli tell you what number is next. Letting patients know we don't have pediatrics at our hospital or don't treat chronic pain with IV Dilaudid might be useful to them. Our patients make a choice to show up in the ED. Is it better to hide information from them? Where else would this be acceptable?

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The $500 Band-Aid

We should re-envision the medical screening exam entirely. It often pits patients against the ED, and does not allow practical information to be exchanged before it. Most of us can eyeball a patient and decide what he needs. We also know there are alternatives to the ED. The triage, intake, and MSE often trigger a bill for the patient, leaving patients with a $500 Band-Aid and dissatisfaction on both sides. The patient is upset he waited three hours to be told his cut doesn't need stitches (many also feel embarrassed for wasting their and the doctor's time), and the ED team is annoyed that they have a waiting room full of unhappy patients (and they have to write discharge instructions for them).

Why not allow the doctor and patient to have a quick conversation where the doctor can give basic medical advice? “Honestly, I'd probably just take ibuprofen, and see how you're feeling in the morning,” or “I'd use a Band-Aid and keep it clean.” It would decompress our waiting rooms, make patients happier, and give many of our low-acuity patients what they really want from us: reassurance that they can manage at home and not have permanent damage. I don't like being the face of a big medical bill and potential financial ruin. Does anyone?

Why not throw in some liability, documentation, and compensation improvements while we're at it? The patient agrees that these “ED curbsides” aren't thorough enough to constitute a doctor-patient relationship (so malpractice doesn't apply), the doctor can write a two-line note about what was said, and the patient has a small co-pay for a small bill.

I'd also like some help with ED crowding. Multiple studies show crowding is caused by a throughput problem on the inpatient and hospital end, not from a dysfunctional ED. Why not mandate that hospitals, not EDs, put their skin in the game? Reward hospitals that do more with less. Punish hospitals that allow EDs to board patients for days. This would require the hospital to smooth its elective OR schedule (a key reason hospitals are full; cases with “reserved” beds for later) and to come up with creative ways to make the entire hospital more efficient.

I'd also love mandated help with our most challenging patients. Require that states or counties provide resources of the local ED's choosing. Some places may struggle with substance abuse; others may need mental health support; still others could use adult day care. If we continue to mandate that the ED see all-comers at all hours for all reasons, give us some resources to help ourselves (and our communities) and allow us to decide how to allocate them.

Emergency medicine is one of the youngest medical specialties, but in its 40-something years, it has become one of the largest and most important pillars of care. We proudly care for everything that comes through our doors. If there's one trait that unites us, it's our ability to adapt to every situation. Why not redefine the way we think our EDs should be run, tell the policymakers what we know about delivering safe, efficient, and effective care, and create a system that doesn't punish our patients for seeking care or punish us for being available for everyone?

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