Every hospital ER knows the type. He's the patient who shows up like clockwork every Friday or Saturday night. He never has an emergency medical condition. He comes in complaining about vague symptoms. He usually demands to see a physician immediately and insists his pain is so great that he absolutely has to have pain medicine, the stronger the better. This same patient may be violent and abusive to staff and other patients.
He may be drunk or high at the time he presents to the ER and, to top everything, he usually is uninsured and does not pay his bill for the ER services.
What can you do about this patient? In dealing with disruptive or abusive patients in the ER, a hospital must walk a fine line. On the one hand, federal and most state laws impose an obligation on hospitals to provide emergency treatment to anyone, regardless of whether they are likable. On the other hand, a hospital needs to keep its ER available for true emergencies, and devoting time and resources to regulars who come in with frivolous complaints can hinder a hospital's ability to provide emergency services to those who truly need them.
As long as a hospital provides an emergency evaluation and emergency treatment to everyone who comes to the ER, however, there are steps the hospital can take to minimize the extent and the number of these non-emergency abusive patient visits.
EMTALA Obligations
Every hospital with an emergency room has certain obligations, including those imposed by the federal Emergency Medical Treatment and Active Labor Act (EMTALA). The duties normally owed to any patient are to:
- Stabilize an emergency medical condition.
- Provide emergency treatment that meets acceptable medical standards.
- Make patients aware of their conditions and of the need to obtain follow-up care.
If a patient comes to the ER and requests care, the hospital must provide a screening exam to determine whether the patient suffers from an emergency medical condition. If the exam reveals an emergency medical condition, the hospital must stabilize the patient or make a legal transfer of the patient to a hospital that can provide such stabilizing treatment.
A hospital or responsible physician that negligently violates EMTALA is subject to a civil monetary penalty. In addition, an injured patient may obtain civil damages and equitable relief from the hospital.
At a minimum, therefore, every hospital with an ER must provide a screening exam to any patient who presents to the ER so as to determine if the patient is suffering from an emergency. If an emergency does exist, the patient must be stabilized.
Non-Emergency Care
If it is determined the patient is not suffering from an emergency or other condition that requires immediate treatment, it is acceptable for the ER physician to send the patient home. If the patient needs follow-up care, the doctor can either schedule an appointment with the patient or recommend other follow-up care. It should be kept in mind that normally an ER patient has no right to expect anything more from the hospital and the ER physician than the treatment of his immediate medical condition. ER treatment does not generally establish an ongoing physician/patient relationship between the ER physician and the patient.
If the ER physician schedules a patient for follow-up care, however, the physician is taking the risk that such action would create a physician/patient relationship. In that case, it may become difficult for the physician to subsequently terminate the relationship. Consequently, if the ER patient is particularly disruptive or non-compliant, the ER doctor might not wish to schedule a follow-up visit with the patient. Instead, he may choose to provide the patient with a list of alternative providers or clinics in the community. As long as the ER physician makes it clear that the patient has full responsibility for obtaining his own follow-up treatment, the ER physician should not be held liable for patient abandonment. In general, patient abandonment occurs only when the patient has a reasonable expectation of an ongoing physician/patient relationship and is then injured because the doctor did not fulfill his duty to provide the expected ongoing treatment.
Policy for Disruptive Patients
If a hospital has a particular problem with disruptive or abusive patients requesting non-emergency care, it may consider developing a written policy providing a consistent way to handle those patients.
Such a policy should be carefully thought out and should require that all patients will be provided emergency screening and treatment. The policy also may provide, however, that the hospital can send disruptive or dangerous patients a letter advising them of alternative providers in the community who are able to provide non-emergency care. The letter should state clearly that the hospital will continue to provide emergency screening and treatment, but that in order to preserve ER resources for those who truly need them, the hospital is requesting that the patient limit his visits to emergencies.
Any hospital that sends such a letter must be very careful to use the letters in a consistent, non-discriminatory fashion. Patients should not be singled out based on their background, appearance or personal hygiene (or lack thereof). A hospital also should keep in mind that the very patients who abuse the ER for non-emergency visits are the same ones who will be the most likely to sue alleging discrimination upon receipt of such letters. For this reason, a hospital should consider consulting an attorney prior to adopting any disruptive ER patient policy.
In addition, the hospital should check its state laws. Some states have laws imposing a higher obligation than EMTALA. Moreover, if the patient is covered by a third party insurer such as Medicare, Medicaid or a private insurance plan, the hospital should, of course, check its participation agreement with that insurer before sending such a letter. Many third party insurers have specific requirements for how a hospital or other provider can discontinue providing treatment to a patient covered by the insurer.
Security
If the patient is disruptive to an extent that he presents a danger to the hospital staff or other patients, there is nothing in the EMTALA law to prevent the hospital from having security guards on hand during the patient's treatment. Moreover, if the patient assaults a hospital employee or another patient, the hospital can and should, in some circumstances, call local law enforcement.
Although a hospital ER is somewhat restricted by EMTALA in its ability to deal with disruptive patients, there are certain steps hospitals can take to try to minimize the disruptive effects of a drunk, disorderly or violent non-emergency patient. The best course is to adopt a written policy so all disruptive, non-emergency patients are treated consistently and are not singled out on a discriminatory or illegal basis.