Court Rules Deviation From Triage System Is EMTALA
Violation -- Returns Case for Trial
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The US Court of Appeals for the First Circuit has ruled that
deviation from the triage classifications of the hospital may
state a cause of action for violation of the screening and
stabilization requiremenst of EMTALA, and overturned a
lower court order dismissing the case.

The case of Edgardo Jose Cruz-Queipo, et al, vs. Hospital
Espanol Auxilio Mutuo De Puerto Rico, decided on July 27.

According to the court opinion, the plaintiff alleged that the
patient presented at 4:00 pm with complaints of chest pain, arm
pain and wrist pain which was a Triage Level 2 complaint
under the hospital's triage classification system. The
patient was triaged by a physician as a Level 4 (lower
priority) as back and muscle pain. Chest pain complaints
were not documented in the record at any point. The
patient received an exam by another physician at 5:30
pm . An EKG and cervispinal x-ray were performed. The
patient was subsequently discharged with a diagnosis of
thoracic outlet syndrome.

The following day the patient returned to the hospital
emergency department with severe chest pain radiating to
his left arm and jaw. He was diagnosed with an acute
myocardial infarction and remained in the CCU for a week,
and then was transfered for 6x CABG. He allegedly sustained permanent damage that could have been prevented by timely diagnosis and treatment on the first visit.

The hospital conceded that if the patient had complained
of chest pain, a different protocol of treatment would have
been required. A conflict of evidence on the issue of whether
or not the patient had complained of chest pain required
reversal of the summary judgment for the hospital and return
to the trial court for a jury trial, according to the court's ruling.

Among the court's comments:

"A hospital fulfills its statutory duty to screen patients in its
emergency room if it provides for a screening examination
reasonably calculated to identify critical emdical conditions
that may be afflicting symptomatic patients and provides
that level of screening uniformly to all those who present
with substantially similar complaints."

"The essence of this requirement is that there be some
screening procedures, and that it be administered even-
handedly. When a hospital prescribes internal procedures
for a screening examination, those internal procedures
set the parameters for an appropriate screening."

...

"Cruz's placement in Category IV despite a complaint of
chest pains thus marked a departure from the hospital's
standards, which set the parameters for an appropriate
screening."

"...the plaintiffs assert that if we accept that Cruz complained
of chest pains during his August 31 visit, we must also
conclude that the hospital had a duty to stabilize the heart
condition that culminated in a heart attack on September 1.
We agree."

"footnote 6 -- ....Specifically, Auxilio Mutuo claims that Cruz's
heart condition was attributable to his 'inability to adequately
care for his physician condition' by controlling his
cholesterol and blood pressure, rather than to any action or
omission of the hospital. This argument is a non-starter.
Hospitals general do not cause the emergency conditions
that they are called upon to stabilize under EMTALA. That
does not mean, however, that a hospital's failure to stabilze
a condition bears no causal relationship to the damages
suffered by a patient as a result of a deterioration in his
condition that could have been avoided by stabilization."

While this case must return for trial, and whether or not t
he patient complained of chest pain and whether the patient
was improperly triaged and disparately treated, this case
supports the standard CMS practice of citing hospitals for
violation of their own policies and procedures.The issue typically arises for failing to note triage catagories or
selectively down-grading patients to lower classifications
than specified in the policies.

The initial reaction of many facilities may be to suggest
that they will remove classifications or make them entirely
subjective. CMS, however, has repeatedly cited for lack of
clear triage classification standards and practice.

It is particularly salient that the deviation from the Triage s
ystem was not the result of a nursing judgment, but occurred
based on a physician judgment. It is not uncommon to
encounter the assumption in hospitals that the physician
can over-ride the triage system. The message from this
decision is the one that many triage trainers have
emphasized for many years -- you can upgrade patient acuity
classifications from the standard, but you cannot
down-grade them.