Often, clinicians such as nurse practitioners (NPs) or physician assistants (PAs) who work in hospitals or health centers are not sued for errors themselves; instead, their employer is sued.
There are several reasons for this, the main one being that a hospital has much deeper pockets than does an individual practitioner, and the hospital is, in essence, responsible for the actions of its employees. This month’s case involves an NP who got caught in this situation.
The patient, Ms. A, was a 48-year-old divorced mother of two teenage sons. One night, at 12:30 AM, she awakened with chest pain. When it didn’t resolve she called 911, and emergency medical personnel arrived at 1:50 AM. The emergency medical services (EMS) technicians noted that Ms. A was diaphoretic, was complaining of substernal chest pressure, and had a history of hypertension but had stopped taking her medication.
Ms. A’s electrocardiogram (ECG) results were normal, and she was given a nitroglycerin spray at 1:54 AM, but there was no reported change. Her blood pressure was measured at 230/130 mm Hg, and then at 216/143 mm Hg at 2:08 AM, and she was given two more nitroglycerin sprays over the next few minutes.
By 2:12 AM, the patient’s blood pressure had dropped to 199/140 mm Hg, and then to 177/141 mm Hg a minute later. She was transported by ambulance to the emergency department of the local hospital, where she was triaged at 2:22 AM. It was noted that she was alert and not in acute pain at the time, but her chest pain was described as being on the left side and radiating to her back. At this point, the NP who was on duty that night, Mr. F, took the case.
Mr. F, aged 30 years, had been working in the hospital’s emergency department for the past 3 years. He didn’t mind the night shift, as it enabled him to spend time with his toddler during the day. Sometimes, however, the small nighttime staff made for challenges.
Mr. F looked over Ms. A’s paperwork and ordered another ECG and lab work. He then went in and spoke to Ms. A, who was complaining of the pain again. Mr. F noted that the patient appeared uncomfortable and that her chest pain was reproducible. At 3:00 AM, Mr. F recorded that the patient was ready for evaluation by the physician, and that the chart had been flagged for the doctor.
However, almost 2.5 hours passed before the physician, Dr. S, saw the patient. In the meantime, Mr. F continued to check on her. He noted that he had to replace Ms. A’s intravenous line at 3:45 AM after she accidently pulled out the one inserted by the EMS technicians.
When Mr. F saw Dr. S in the hallway, he mentioned to her that the patient needed pain relief. Later, Mr. F had a discussion with the physician about the blood tests Mr. F had ordered.
Finally, at about 5:30 AM, Dr. S saw the patient, ordered aspirin and sublingual nitroglycerin, and mentioned to Mr. F in passing that she thought it was a gallbladder problem but that the patient would have to be admitted to rule out the chest-pain issues.
After the physician left the room, Mr. F administered the aspirin and nitroglycerin 0.4 mg sublingual. Immediately after being given the medicine, Ms. A said, “I don’t feel right,” and appeared to have a seizure. When no pulse was detected, cardiopulmonary resuscitation (CPR) was started and the patient was intubated and given code medications in an attempt to revive her. All attempts failed, and at 6:20 AM, Ms. A was pronounced dead. The autopsy revealed the cause of death to be hemopericardium from a ruptured aortic dissection.
Several months later, Mr. F, Dr. S, and the hospital were notified that the hospital was being sued by the family of Ms. A for wrongful death. The plaintiffs claimed that the hospital failed to properly screen Ms. A as required by the Emergency Medical Treatment & Labor Act (EMTALA).
Mr. F was called in for a deposition, and was questioned by the opposing counsel about the hospital’s EMTALA policy for patients presenting with chest pain. Mr. F could only say that such patients were screened and stabilized; he realized as he spoke that he did not know the hospital’s exact policy.
“Do you have a copy of the written procedures for screening patients with chest pain?” asked the attorney. “Were you provided with that when you were hired? Or were you given verbal instructions about the hospital’s specific policy?”
Mr. F had to admit that he did not recall any written procedure or specific policy.
When the physician was called to the stand, she, too, was unable to explain what the policy was, or why she hadn’t seen the patient earlier under the circumstances.
The hospital’s attorneys filed a motion to dismiss the case, claiming that the patient had been screened appropriately. The court denied the dismissal, and the case eventually settled out of court for a sum of $1 million.
EMTALA was enacted by Congress in 1986 in response to concerns that hospitals were either refusing to treat certain emergency patients or transferring them to other institutions based on financial considerations.
Pursuant to EMTALA, hospitals are required to provide the following medical care to any individual who presents for emergency treatment: appropriate medical screening, stabilization of known emergency medical conditions and labor, and restrictions on transfer of unstabilized individuals to outside hospital facilities.
Although the statute doesn’t specify what an “appropriate medical screening” is, courts have interpreted it as requiring hospitals to provide uniform screening to all those who present with similar complaints. Therefore, it is the responsibility of the hospital to determine what the screening procedures will be, and apply them to all patients.
In this case, neither Mr. F nor Dr. S were able to state what the hospital’s screening policy was for patients with chest pain, and thus, there was no way to determine whether Ms. A had been screened properly or whether she had been screened in a manner uniform with similar patients. Therefore, the court could not dismiss the case.
The hospital needed to have a policy in place, and the clinicians needed to know what it was. The policy needed to be followed for all similar patients, and the hospital needed to provide the policy to its employees and make sure that it was followed.
Mr. F and Dr. S both needed to know what the policy was, needed to be able to explain it, and needed to utilize it consistently. The fact that neither practitioner could explain what the policy was doomed the hospital to not having a strong defense against the lawsuit.
If you work in a hospital with an emergency department, it is essential that you familiarize yourself with your hospital’s policy for screening patients under EMTALA. Whether the policy is written or verbal, knowing clearly what it is will protect you, your patient, and your employer.
Anne W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.